AUTHOR AND EDITOR INFORMATION

Section 1 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

INTRODUCTION

Section 2 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Background

Since the 1950s, several investigators have published reports of patients with dysphagia who had associated lower esophageal ringlike constrictions, but each investigator had a different opinion as to the cause and nature of these rings. In 1953, Ingelfinger and Kramer believed that these rings occurred as a result of a contraction by an overactive band of esophageal muscle; however, Schatzki and Gary believed that these rings were fixed and not contractile. Some of this controversy may be related to the confusion of categorizing muscular and mucosal rings under the same entity, as concluded by Goyal et al.

Two rings have been identified in the distal esophagus. The muscular ring, or A ring, is a thickened symmetric band of muscle that forms the upper border of the esophageal vestibule and is located approximately 2 cm above the gastroesophageal junction. The A ring is rare; furthermore, it is even more rarely associated with dysphagia. On the other hand, the mucosal ring, or B ring, is quite common and is the subject of discussion in this article. The B ring is a diaphragmlike thin mucosal ring usually located at the squamocolumnar junction; it may be symptomatic or asymptomatic, depending on the luminal diameter.

The pathogenesis is not clear, and patients typically present with intermittent nonprogressive dysphagia for solids. Fortunately, most patients respond well to initial and repeat dilatation therapy. A small number of patients may have stubborn rings that require more aggressive endoscopic or surgical intervention.

Pathophysiology

The pathogenesis of Schatzki rings is not clear, and at least 4 hypotheses have been proposed. These hypotheses may not be mutually exclusive. Proposed hypotheses are as follows:

1. The ring is a pleat of redundant mucosa that forms when the esophagus shortens transiently or permanently for unknown reasons.
2. The ring is congenital in origin.
3. The ring is actually a short peptic stricture occurring as a consequence of gastroesophageal reflux disease.
4. The ring is a consequence of pill-induced esophagitis.

Data supporting or refuting the first 2 hypotheses are few.

Data about the association of gastroesophageal reflux disease and rings are inconclusive or contradictory. It has been hypothesized that the ring acts as a protective barrier against further reflux. However, in one recent study involving 20 patients, no significant differences were noted in any of the reflux parameters measured before and after dilation. In fact, it was interesting to note that thick rings may actually decrease esophageal acid clearance, especially in the supine position, thereby increasing esophageal acid exposure.

The last hypothesis was based on a chance observation in one study showing that 62% of patients with rings had ingested medications known to cause pill-induced esophagitis.

In some studies, the severity of symptoms has clearly been demonstrated to correlate with the luminal diameter. Dysphagia predictably occurs in patients with a luminal diameter less than 13 mm and may vary between 13-20 mm, depending on the size and type of bolus.

Frequency

United States

Schatzki ring is quite common and may be found in as many as 15% of all patients undergoing barium swallow studies; however, few of these patients exhibit any symptoms of dysphagia.

International

No data are available.

Mortality/Morbidity

• No mortality has been ascribed to this entity.
• Morbidity is variable. Most episodes of dysphagia are short lived, and intervening periods between episodes may vary from weeks to months or even to years.

Race

No known race predilection exists.

Sex

No known sex predilection exists.

Age

Although no known predilection for a specific age group exists, most patients are older than 40 years at presentation.

CLINICAL

Section 3 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

History

• Most patients present with intermittent, episodic, nonprogressive dysphagia to solids. Dysphagia to liquids is usually not present.
• • The episode of dysphagia appears to be short lived.
  • Typically, the patient ate a meal in a hurried fashion.
  • The bolus of food may occasionally be forced down by drinking liquids, or may be regurgitated to relieve the obstruction.
  • After forcing the bolus through or regurgitating it, the patient can usually finish his or her meal without difficulty.
  • Dysphagia may not recur for months or years in these patients. Daily dysphagia is unlikely to be caused by a Schatzki ring.
• Bread (especially freshly baked) and meat appear to be common foods that frequently precipitate symptoms. Patients often present after rapidly eating meat and drinking alcohol at a restaurant; hence, some authorities equate Schatzki ring to the "steakhouse syndrome."
• Associated symptoms of heartburn and regurgitation characteristic of gastroesophageal reflux disease may occur in some patients.

Physical

• Physical examination findings are usually unremarkable.
• The patient may salivate and drool if the offending food bolus continues to completely obstruct the lower esophagus for a longer duration, but this scenario is excessively rare.

DIFFERENTIALS

Section 4 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

WORKUP

Section 5 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Imaging Studies

• Barium esophagram
• • Perform a prone full-column barium esophagram as the initial study because it is more sensitive than double-contrast radiography or endoscopy, especially when the luminal diameter is more than 10 mm. (See Media files 1-2.)
  • Distending the lower esophagus by performing the Valsalva maneuver enhances sensitivity.
  • The sensitivity may be further improved by using a barium tablet or a coated marshmallow.

Procedures

• Esophagogastroduodenoscopy
• • Although barium studies are performed initially, esophagogastroduodenoscopy is performed subsequently to confirm the diagnosis and to exclude any other diagnosis.
  • Endoscopic examination evaluates the mucosa of the distal esophagus, confirming the diagnosis of concomitant gastroesophageal reflux disease or a short peptic stricture instead of a ring.

Histologic Findings

The upper surface of a Schatzki ring is covered by squamous epithelium, and the lower surface is covered by columnar epithelium because the ring is usually located at the squamocolumnar junction. The ring is composed of the mucosa and submucosa and does not contain the muscularis propria. Occasionally, the lamina propria may contain fibrous tissue.

TREATMENT

Section 6 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Medical Care

Using a large French mercury bougie, polyvinyl bougie, or a balloon, esophageal dilatation is used with the intention of fracturing the ring—not merely stretching it.

• After initial dilatation, aggressively treat any associated reflux disease. In one prospective, randomized, placebo-controlled study involving 44 consecutive patients, acid suppressive maintenance therapy with omeprazole after bougienage was shown to prevent relapse of the ring as compared to the placebo group. The duration of follow-up was about 60 months, and the mean duration of relapse was 19.9 months.
• Subsequent dilatations may be needed for recurrence of dysphagia. Determine the need for such dilatations on an individual basis. However, in one study involving only 11 patients, objective measurements with a 12.7-mm barium pill showed that the pill failed to pass the ring in 60% of patients at 1 month and 100% of patients at 1 year. This suggests that recurrence of dysphagia is not a reliable indicator of relapse or persistence of the ring.
• If dysphagia persists or recurs shortly after dilatation, consider an esophageal manometry study to look for any treatable motility disorder.
• If the manometry does not reveal any treatable motility disorder, consider repeating an upper endoscopy to assure healing of esophagitis or to confirm persistence of the ring.
• Based on anecdotal reports, larger pneumatic balloons, such as balloons used for achalasia dilatation, may be considered if the ring persists despite 2 or more bougie dilatations. Fortunately, this measure is rarely required. Use larger balloons with extreme caution because of the increased risk of perforation.
• Successful endoscopic electrocautery incision using a needle-knife papillotome has been reported and may be considered. A recent randomized, controlled trial compared 52-Fr Maloney dilator versus 4 quadrant biopsy of the ring and found that both modalities were equally effective in relieving dysphagia at 3 months and at 12 months in 26 patients. However, 100% of the biopsy group described the procedure as easy as opposed to 55% of the dilation group.

Surgical Care

On very rare occasions, one may have to resort to surgical excision if medical therapy fails. Antireflux surgery may also be considered at the same time for concomitant gastroesophageal reflux disease.

Consultations

On very rare occasions, one may have to resort to surgical excision if medical therapy fails. Antireflux surgery may also be considered at the same time for concomitant gastroesophageal reflux disease.

Diet

No major dietary restrictions are applicable. The patient may be advised to avoid eating quickly and to chew his or her food well, especially meat and bread; however, whether this advice is truly beneficial is unclear.

Activity

No restrictions on activity are applicable.

MEDICATION

Section 7 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

No specific drug therapy for Schatzki ring exists. Consider treating any associated reflux disease with potent antisecretory agents (eg, proton pump inhibitors).

Drug Category: Proton pump inhibitors

Inhibits H⁺/K⁺-ATPase enzyme system in the gastric parietal cells, resulting in decreased gastric acid secretion. Used for esophagitis or unresponsiveness to H2-antagonist therapy.

FOLLOW-UP

Section 8 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Further Outpatient Care

• Recurrence of dysphagia decreases with increasing experience with dilatation.
• Repeat esophageal dilatation with a large-bore bougie in patients whose dysphagia recurs.
• Monitor patients in follow-up visits (eg, q1-2mo) after initial dilatation and, subsequently, on an as-needed basis.

In/Out Patient Meds

• If reflux disease is suspected based on symptoms or endoscopic findings, consider proton pump inhibitors in addition to antireflux precautions.

Complications

• Esophageal dilatation for esophageal rings is well established as a safe procedure based on published series; however, potential complications include perforation and bleeding.

Prognosis

• Although results of dilatation are excellent, some series report that patients frequently have recurrence of dysphagia. In one study of 33 patients, 32% had recurrence at 1 year, and 89% had recurrence at 5 years.
• No known prognostic indicators for recurrence of dysphagia exist, except for associated gastroesophageal reflux disease as reported in some studies. Other studies have refuted this contention.
• Reassure patients that the ring is a benign entity; however, prepare them for repeat dilatation in the event of recurrence of dysphagia.

Patient Education

• Practitioners may advise patients to avoid eating quickly and to chew their food well, especially meat and bread.
• Encourage antireflux precautions in patients who have associated reflux disease.

MISCELLANEOUS

Section 9 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Medical/Legal Pitfalls

• Even though dilatation is safe, educate the patient about potential complications of esophageal or gastric perforation and/or bleeding and about subsequent management and outcome.
• Considering the possibility of a short peptic stricture instead of a ring is important, especially if the patient responds poorly to repeat dilatation alone.
• Consider esophageal manometry to exclude any treatable motility disorder, such as achalasia, in patients who have persistent dysphagia or early recurrence after dilatation.

Special Concerns

• In patients with high-risk conditions for developing endocarditis, such as prosthetic heart valves, prior history of endocarditis, systemic-pulmonary shunts, and synthetic vascular grafts less than 1 year old, administer prophylactic antibiotics prior to esophageal dilatation.
• • An acceptable regimen includes 2 g ampicillin parenterally and 1.5 mg/kg (up to 80 mg) gentamicin intravenously 30 minutes prior to the procedure, followed by 1.5 g amoxicillin orally 6 hours after the procedure.
  • A single gram of intravenous vancomycin can be substituted for patients who are allergic to penicillin.

ACKNOWLEDGMENTS

Section 10 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

The authors and editors of eMedicine gratefully acknowledge the contributions of previous coauthor, John Schaberg, MD, to the development and writing of this article.

MULTIMEDIA

Section 11 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Media file 1:  Endoscopic appearance of the distal esophagus illustrating a Schatzki ring.
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Media type:  Photo

Media file 2:  Barium swallow illustrating an indentation at the gastroesophageal junction consistent with a Schatzki ring above a sliding hiatal hernia.
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Media type:  X-RAY

Media file 3:  A Schatzki ring dilated by the passage of a single large bougie.
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Media type:  Image

REFERENCES

Section 12 of 12

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

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Article Last Updated: Apr 18, 2006