Esophageal Webs And Rings


Article Author:
Sami Ghazaleh


Article Editor:
Krunal Patel


Editors In Chief:
Chaddie Doerr


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Kyle Blair
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Daniyal Ameen
Altif Muneeb
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes
Komal Shaheen
Sandeep Sekhon


Updated:
5/2/2019 9:56:19 PM

Introduction

The esophagus is a muscular tube for the propulsion of food from the pharynx to the stomach. Histologically, the esophageal wall consists of mucosa, submucosa, and muscularis propria.[1] Esophageal webs and rings are indentations of the esophageal wall that may partially occlude the esophageal lumen. Esophageal webs and rings are usually asymptomatic but can occasionally present with intermittent dysphagia to solids.

Etiology

The etiology of esophageal webs and rings remains a controversial topic. Several conditions have correlated with esophageal webs and rings. Esophageal webs have classically associated with Plummer-Vinson syndrome which is classically a triad of dysphagia, iron-deficiency anemia, and esophageal webs.[2] Other associated conditions include Zenker’s diverticulum, epidermolysis bullosa, pemphigus vulgaris, and bullous pemphigoid.[3][4][5][6] Esophageal rings, on the other hand, are almost always associated with a hiatal hernia.[7] They also correlate with eosinophilic esophagitis.[8]

Epidemiology

Because most webs and rings are asymptomatic, the true prevalence of these lesions is unclear.[9] Esophageal webs and rings are each identified in 5 to 15% of patients undergoing upper endoscopy for dysphagia.[10]

Pathophysiology

The pathophysiology of esophageal webs and rings is poorly understood. Chronic inflammation can irritate the esophageal wall and produce these lesions.[11] They are also present in the pediatric population suggesting a congenital origin.[12] If webs and rings are big enough, they can narrow the esophageal lumen causing dysphagia and food impaction.

Histopathology

Esophageal webs are usually found in the proximal esophagus and have a covering of squamous epithelium.[10] Esophageal rings, on the other hand, are usually located in the distal esophagus and can be covered with squamous epithelium, columnar epithelium, or both depending on their location to the squamocolumnar junction:

  1. The A rings are located proximal to the squamocolumnar junction. They are covered entirely with squamous epithelium. They are uncommon and usually nonpathological.
  2. The B rings or Schatzki rings are located precisely at the squamocolumnar junction. The proximal part is covered with squamous epithelium, and the distal portion is covered with columnar epithelium. They are the most common type of rings and can become symptomatic.
  3. The C rings are located distal to the squamocolumnar junction. They are covered entirely with columnar epithelium. They are the least common, rarely symptomatic, and usually represent diaphragmatic indentation of the esophagus.[13]

History and Physical

Most esophageal webs and rings cause no symptoms. Patients can become symptomatic if an esophageal web or ring protrudes into the lumen enough to cause esophageal narrowing. Patients usually present with intermittent dysphagia to solid food. Some patients may develop food impaction and will present with acute dysphagia and inability to swallow saliva. In the case of Plummer-Vinson syndrome, patients may demonstrate with the triad of dysphagia, esophageal webs, and iron deficiency anemia.[14]

Isolated esophageal webs and rings usually do not have physical exam findings. However, a comprehensive physical exam may point towards an associated condition. Plummer-Vinson syndrome might have the skin manifestations of iron deficiency anemia including koilonychia, glossitis, and cheilosis.[2] A skin examination may reveal bullous lesions consistent with epidermolysis bullosa or pemphigus vulgaris.

Evaluation

Laboratory testing is rarely useful in patients with suspected esophageal webs or rings. It might be reasonable to obtain a complete blood count and iron studies to look for iron deficiency. However, patients with dysphagia need to be evaluated with barium swallow and/or upper endoscopy. Both procedures can help differentiate between the different etiologies of dysphagia.

A barium swallow is particularly useful in delineating the cause of the esophageal lumen obstruction. It can identify esophageal webs, rings, strictures, tumors, and extraesophageal compression. An esophagogastroduodenoscopy (EGD) is usually necessary for the confirmation of the diagnosis. On EGD, esophageal webs appear as thin membranes that do not span the entire circumference of the esophagus.[2] Esophageal rings also appear as thin membranes, but they span the entire circumference of the esophagus.[14] EGD can also identify other causes of dysphagia including stricture, polyps, and tumors. Moreover, it can allow biopsy of the lesions when suspicion of malignancy exists. Conditions associated with esophageal webs and rings may be identified with an EGD including eosinophilic esophagitis, hiatal hernia, and Zenker’s diverticulum.

Treatment / Management

The main initial treatment of symptomatic esophageal webs and rings is endoscopic esophageal dilatation. The goal of treatment is relief of dysphagia and prevention of symptom recurrence. It is common for esophageal webs to rupture during a diagnostic EGD. Esophageal dilatation is still an option on esophageal webs that have partially ruptured.[15] Esophageal rings require biopsy before dilatation to rule out eosinophilic esophagitis. Following dilatation of esophageal rings, patients often require therapy with a proton pump inhibitor (PPI) because most rings are close to the gastroesophageal junction.[16] Esophageal dilatation is generally safe and effective with low risk of complications.[17]

The major problem with dilatation is the high recurrence rate, especially when used for the treatment of esophageal rings. Therapy with a PPI has been shown to decrease the risk of recurrence following dilatation of esophageal rings.[18] Recurrent symptomatic esophageal rings are treatable with repeat esophageal dilation followed by long-term acid suppression with a PPI. Alternative therapies exist for refractory esophageal rings that failed multiple dilatations. These include incisional therapy using electrocautery and laser division.[19][20]

Differential Diagnosis

The differential diagnosis for esophageal webs and rings is extensive and includes other causes of dysphagia. History and evaluation by barium swallow and/or EGD can help identify those causes. Conditions that may mimic webs and rings include achalasia and esophageal strictures. Achalasia presents with progressive dysphagia to solids and liquids. The classic finding on barium swallow is distal dilatation of the esophagus with a “bird-beak” appearance.[21] Esophageal strictures present with progressive dysphagia to solids. They appear longer than webs and rings on barium swallow and have tapered ends.[22]

Prognosis

The prognosis of esophageal webs and rings is excellent because most patients are asymptomatic. Symptomatic webs and rings are treatable with esophageal dilatation which is safe and effective. The primary concern with therapy is the high recurrence rate following dilatation of esophageal rings. The risk of recurrence improves when using a PPI after dilatation.

Complications

Most esophageal webs and rings do not cause symptoms. Dysphagia occurs when webs and rings protrude into the esophageal lumen leading to luminal narrowing. If the luminal narrowing is severe enough, patients may develop food impaction with the inability to swallow food or even saliva.[15]

Deterrence and Patient Education

Patients should receive education about the benign nature of the condition. This training should include information regarding the alarming signs that indicate the evolution of an occult process. These signs include loss of appetite, weight loss, or bloody stools. They should be advised to take their PPI as prescribed to decrease the risk of recurrence following dilatation.

Enhancing Healthcare Team Outcomes

Coordination of care between health care providers (i.e., the primary care provider, nurse practitioner) is essential for health care outcomes and patient safety. Patients who complain of dysphagia may be encountered in the outpatient clinic by a primary care physician. It is important to ask patients about new symptoms that they may be experiencing. When dysphagia is identified, referral to a gastroenterologist is usually necessary for evaluation. Focused history and examination by the primary care physician in addition to proper documentation can enhance care coordination. Evaluation by gastroenterology may reveal esophageal webs and rings that may require treatment with esophageal dilatation. These findings must be communicated back to the primary care physician. Also, the gastroenterologist should thoroughly explain his recommendations including the need for a repeat EGD or the need for a PPI. 


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Esophageal Webs And Rings - Questions

Take a quiz of the questions on this article.

Take Quiz
Which of the following is true of esophageal webs?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is the best test for diagnosing an esophageal web?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following treatments is no longer used to treat esophageal webs?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Esophageal webs are most likely to cause which symptom?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Select the treatment least appropriate for esophageal webs and rings.



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is not associated with Esophageal webs?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is not seen in patients with esophageal webs?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 17-year-old female patient presents with intermittent dysphagia to solids. Upper endoscopy reveals a thin membrane that does not span the entire circumference of the esophagus located at the cervical esophagus. Which of the following should be expected to be found in this patient?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient who complains of dysphagia was found to have a Schatzki ring at the lower esophagus. He underwent upper endoscopy with endoscopic esophageal dilatation. What is the most appropriate next step in management?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Esophageal Webs And Rings - References

References

Yazaki E,Sifrim D, Anatomy and physiology of the esophageal body. Diseases of the esophagus : official journal of the International Society for Diseases of the Esophagus. 2012 May;     [PubMed]
Novacek G, Plummer-Vinson syndrome. Orphanet journal of rare diseases. 2006 Sep 15;     [PubMed]
Low DE,Hill LD, Cervical esophageal web associated with Zenker's diverticulum. American journal of surgery. 1988 Jul;     [PubMed]
Ergun GA,Lin AN,Dannenberg AJ,Carter DM, Gastrointestinal manifestations of epidermolysis bullosa. A study of 101 patients. Medicine. 1992 May;     [PubMed]
Hokama A,Yamamoto Y,Taira K,Nakamura M,Kobashigawa C,Nakamoto M,Hirata T,Kinjo N,Kinjo F,Takahashi K,Fujita J, Esophagitis dissecans superficialis and autoimmune bullous dermatoses: A review. World journal of gastrointestinal endoscopy. 2010 Jul 16;     [PubMed]
Foroozan P,Enta T,Winship DH,Trier JS, Loss and regeneration of the esophageal mucosa in pemphigoid. Gastroenterology. 1967 Mar;     [PubMed]
Müller M,Gockel I,Hedwig P,Eckardt AJ,Kuhr K,König J,Eckardt VF, Is the Schatzki ring a unique esophageal entity? World journal of gastroenterology. 2011 Jun 21;     [PubMed]
Müller M,Eckardt AJ,Fisseler-Eckhoff A,Haas S,Gockel I,Wehrmann T, Endoscopic findings in patients with Schatzki rings: evidence for an association with eosinophilic esophagitis. World journal of gastroenterology. 2012 Dec 21;     [PubMed]
Wilcox CM,Alexander LN,Clark WS, Localization of an obstructing esophageal lesion. Is the patient accurate? Digestive diseases and sciences. 1995 Oct;     [PubMed]
Kahrilas PJ,Kim HC,Pandolfino JE, Approaches to the diagnosis and grading of hiatal hernia. Best practice     [PubMed]
Chen YM,Gelfand DW,Ott DJ,Munitz HA, Natural progression of the lower esophageal mucosal ring. Gastrointestinal radiology. 1987;     [PubMed]
Anderson LS,Shackelford GD,Mancilla-Jimenez R,McAlister WH, Cartilaginous esophageal ring: a cause of esophageal stenosis in infants and children. Radiology. 1973 Sep;     [PubMed]
Hirano I,Gilliam J,Goyal RK, Clinical and manometric features of the lower esophageal muscular ring. The American journal of gastroenterology. 2000 Jan;     [PubMed]
SCHATZKI R, THE LOWER ESOPHAGEAL RING. LONG TERM FOLLOW-UP OF SYMPTOMATIC AND ASYMPTOMATIC RINGS. The American journal of roentgenology, radium therapy, and nuclear medicine. 1963 Oct;     [PubMed]
Smith MS, Diagnosis and management of esophageal rings and webs. Gastroenterology     [PubMed]
Eckardt VF,Kanzler G,Willems D, Single dilation of symptomatic Schatzki rings. A prospective evaluation of its effectiveness. Digestive diseases and sciences. 1992 Apr;     [PubMed]
Mann NS, Single dilation of symptomatic Schatzki ring with a large dilator is safe and effective. The American journal of gastroenterology. 2001 Dec;     [PubMed]
Sgouros SN,Vlachogiannakos J,Karamanolis G,Vassiliadis K,Stefanidis G,Bergele C,Papadopoulou E,Avgerinos A,Mantides A, Long-term acid suppressive therapy may prevent the relapse of lower esophageal (Schatzki's) rings: a prospective, randomized, placebo-controlled study. The American journal of gastroenterology. 2005 Sep;     [PubMed]
Wills JC,Hilden K,Disario JA,Fang JC, A randomized, prospective trial of electrosurgical incision followed by rabeprazole versus bougie dilation followed by rabeprazole of symptomatic esophageal (Schatzki's) rings. Gastrointestinal endoscopy. 2008 May;     [PubMed]
Roy GT,Cohen RC,Williams SJ, Endoscopic laser division of an esophageal web in a child. Journal of pediatric surgery. 1996 Mar;     [PubMed]
Reynolds JC,Parkman HP, Achalasia. Gastroenterology clinics of North America. 1989 Jun;     [PubMed]
Marks RD,Richter JE, Peptic strictures of the esophagus. The American journal of gastroenterology. 1993 Aug;     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of CNS-Pediatric. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for CNS-Pediatric, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in CNS-Pediatric, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of CNS-Pediatric. When it is time for the CNS-Pediatric board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study CNS-Pediatric.