Many years ago, Schatzki described a smooth, benign, circumferential, and narrow ring of tissue in the lower end of the esophagus (the food pipe that connects the mouth to the stomach). These rings are located just above the junction of the esophagus with the stomach.
These rings are common. The cause of these rings is not clearly understood, while some doctors believe they are caused by long term damage from stomach acid reflux.
The pathophysiology of Schatzki ring is not fully known. Various hypotheses include congenital origin, arising from a pleat of redundant mucosa, or as a result of gastroesophageal reflux or esophagitis.
Some investigators have demonstrated that Schatzki rings become narrowed during serial radiographic examinations and that they transform into actual peptic strictures.
Even so, endoscopic biopsy and 24-hour esophageal pH monitoring have failed to show any symptoms or signs of gastroesophageal reflux or reflux esophagitis in more than one third of patients with Schatzki rings.
Schatzki ring is a common cause of intermittent dysphagia. In fact, in a large endoscopic series, it was the fourth most common endoscopic finding in endoscopic evaluation of dysphagia after esophageal stricture, normal endoscopy, and esophagitis/ulcer.
The main morbidity associated with lower esophageal rings is dysphagia, but many remain asymptomatic. Schatzki ring is a common cause of dysphagia. Typically, the dysphagia is intermittent or short-lived.
Food may become stuck in the esophagus but can be forced down by drinking liquids or may be regurgitated. The dysphagia may not recur for months or years. Patients may have associated symptoms of gastroesophageal reflux.
There should be no direct mortality with this condition.
Schatzki ring are fixed anatomic mucosal ring structures in the distal esophagus. They are distinct from lower esophageal muscular rings (A rings), which are transient, smooth, circumferential indentations in the esophagus.
What are symptoms of a Schatzki Ring?
The majority of these rings cause no symptoms, and patients are unaware of their presence. When the opening of the esophagus becomes smaller as the diameter of these rings shrink, solid, poorly chewed food (such as steak, turkey, frankfurter) that stays in chunks can get caught at the level of the ring.
This occurs when the diameter of the ring reaches approximately 1 cm. The patient then experiences chest pain, or sticking sensation in the chest with swallowing (referred to as dysphagia).
If the chunk of food passes into the stomach, these symptoms subside quickly and the patient can resume eating. If the food does not pass into the stomach, some patients have to induce regurgitation of the food by sticking their finger in the back of their throat before they can resume eating.
Rarely, the food becomes impacted (the food cannot pass nor can it be regurgitated). These patients experience continued chest pain and difficulty swallowing saliva and secretions.
A flexible endoscope has to be inserted through the mouth into the esophagus to extract the impacted food to relieve the obstruction.
How is a Schatzki Ring diagnosed?
The diagnosis of Schatzki ring can usually be made by barium x- ray examination of the esophagus; however, a narrow ring can be missed on x-ray.
In patients with symptoms of dysphagia, doctors usually also order an upper endoscope examination. Endoscopy is the best way of diagnosing a Schatzki ring.
During the endoscopy, a flexible viewing tube is inserted through the mouth into the esophagus. It allows a direct view of the inner lining of the esophagus and the stomach.
The test helps to exclude early cancer, esophagitis, and Barrett’s esophagus.
What treatment is for Schatzki Ring?
Management of these rings involves procedures that will stretch or fracture these rings, thus allowing freer passage of solid food.
Stretching or fracturing can be performed with endoscopes or tapered dilators inserted through the mouth, also by deflated balloons that are placed across the ring and are then blown up.
Open surgery is hardly ever necessary to handle these rings.
Barium esophagography is the preferred method of detection of Schatzki rings.
Single-contrast esophagography performed with the patient drinking in the prone position is more sensitive in detecting lower esophageal mucosal rings than is erect double-contrast imaging of the esophagus.
Upper gastrointestinal endoscopy is commonly used for the evaluation of dysphagia. Upper endoscopy may not be as sensitive as barium esophagography in detecting lower esophageal rings.
In one study, endoscopy failed to depict more than one third of radiologically demonstrated lower esophageal rings, half of which had caused symptoms and dysphagia.
Limitations of techniques
Esophageal rings may be missed during barium esophagography if distention of the distal esophagus is inadequate; therefore, adequate distention of the esophagus during barium esophagography is imperative.
This distention is best achieved by using a single-contrast technique in the prone or right or left anterior oblique position with large boluses of barium.
A modified Valsalva maneuver also may help in demonstrating the ring by distending the associated hiatal hernia.