Mr Runyon, a 55 year old mechanic presents with intermittent dysphagia. His endoscopy showed:
What is the diagnosis?
Schatzki ring
What is a Schatzki ring?
Schatzki ring is a lower oesophageal mucosal ring that causes intermittent dysphagia.
Lower oesophageal rings are common and is found in up to 15% of barium examinations. The vast majority of them are asymptomatic. The term Schatzki ring is reserved for lower oesophageal rings that cause symptoms.
Lower oesophageal rings (also called B rings) are composed of mucosa and submucosa. It occurs at squamo columnar junction and thus the histology correspond to the OG junction: the superior surface of the ring is stratified squamous epithelium (ie, oesophageal mucosa), and the inferior surface of the ring is covered by columnar epithelium (ie, gastric mucosa).
The exact pathogenesis of lower oesophageal rings is not known. Most investigators believe that a Schatzki ring is an annular stricture caused by scarring from reflux oesophagitis.
What are the clinical manifestations of Schatzki rings?
Most cases occur in middle-aged or older adults.
The cardinal manifestation of Schatzki rings is intermittent dysphagia for solid foods.
Patients also may present with acute food impaction causing an obstruction in the oesophagus.
Discuss the diagnosis of Schatzki ring?
Barium swallow is more sensitive than OGD. Endoscopy failed to show 1/3 of Schatzki rings demonstrated on barium swallow in one study. However, endoscopy is needed to confirm the diagnosis and exclude any other diagnosis once Schatzki ring is picked up on barium swallow.
Discuss the treatment of Schatzki ring?
Treatment is needed only in symptomatic patients. Treatment options:
- Oesophageal dilatation is used with the intention of fracturing the ring—not merely stretching it. Given their dense, fibrous nature, balloon dilatation is preferred (due to their radial force on the ring)
- Incision of the ring using electrocautery or sphincterotome or Nd:YAG laser.
- 4-quadrant biopsy of the ring is as effective as dilatation.
What are the types of oesophageal rings?
Two types of rings are identified in the distal oesophagus.
A ring- or muscular rings. It is a thickened symmetric band of muscle that is located approximately 2 cm above the GO junction. This muscular ring is not a fixed structure and only may be demonstrated in some barium swallows. ‘A’ rings are rare and even more rarely associated with dysphagia.
B ring or mucosal ring is quite common.
What is an oesophageal web?
An oesophageal web is a thin (2-3 mm), eccentric, smooth extension of normal oesophageal tissue consisting of mucosa and submucosa that can occur anywhere along the length of the oesophagus but is typically located in the anterior postcricoid area of the proximal oesophagus. The association between iron deficiency and oesophageal webs is controversial.
Image courtesy of www.gastrointestinalatlas.com
