Schatzki Ring


Article Author:
Lucas Watts


Article Editor:
Krunal Patel


Editors In Chief:
Sebastiano Cassaro
Joseph Lee
Tanya Egodage


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
6/4/2019 6:11:52 PM

Introduction

Richard Schatzki was a renowned radiologist who described a ring-like structure in patients with dysphagia in articles from 1953 to 1963, and that structure would later bear his name. Schatzki ring is described as a circular membrane of mucosa and submucosa that is seen at the squamocolumnar junction of the distal esophagus. It appears as a thin membranous structure that does not contain any muscularis propria. It has an upper surface that is covered with squamous epithelium and a lower surface that is covered with columnar epithelium and is always associated with a hiatal hernia.[1][2][3]

Etiology

As stated previously, Schatzki ring is associated with a hiatal hernia. Gastroesophageal reflux has been thought of as causing the ring. It has been postulated that the creation of a Schatzki ring is the body’s response to frequent acid exposure and natural way of preventing the development of Barrett’s esophagus. Studies have shown that Barrett’s esophagus is less common when a Schatzki’s ring is present, especially long-segment Barrett’s esophagus.[4][5][6]

Epidemiology

Schatzki ring is found in 6% to 14% of barium radiographs done routinely. It is noted to be the most common cause of episodic dysphagia for solids and food impactions in adults. There are no known population studies to suggest how common it is among the general population.

Pathophysiology

As a Schatzki ring develops, it causes narrowing of the distal esophageal lumen that creates an intrinsic mechanical disorder. This will result in symptoms of dysphagia or complications like food impaction when the diameter becomes so small food is unable to pass. The ring does not cause symptoms until it reaches a diameter that obstructs food from passing. Richard Schatski developed the “Schatzki rule” which was that a ring under 13 mm will always have symptoms and a ring larger than 25 mm will always be asymptomatic. In cases where food becomes stuck, patients can develop odynophagia or chest pain.[7][8][9]

Histopathology

As previously described, there is squamous epithelium above the ring and columnar epithelium below it. This differentiates it from esophageal webs, which have squamous (esophageal) epithelium on both sides. In initial studies, it was described as being triangle-shaped on cross section and formed by a core of connective tissue with an overgrowth of muscularis mucosa and smooth muscle fibers creating an annular band.

History and Physical

Most Schatzki rings do not cause symptoms, but the main symptom that does occur is dysphagia and can result in acute dysphagia as a result of food impaction. Symptoms are commonly associated with not very well chewed meat and sometimes described as food sticking in the chest that has been referred to as “Steakhouse syndrome." Symptoms are less commonly associated with globus, which is the sensation of a “lump” or “blockage” between the cricoid and sternal notch. In the case of food impaction, patients can present with odynophagia.

Key questions to ask pertain to the location of discomfort in swallowing, which would be expected to be subxiphoid (lower chest/upper abdominal area), and whether symptoms are worse with solids or liquids or both. The extent of symptoms depends on the diameter of the ring and the largest diameter with symptoms would be less than 25 mm according to the “Schatzki rule.”

Evaluation

Once a patient presents with symptoms suggesting a Schatzki ring, the initial study in evaluation is a barium esophagram. If significant enough, it will show an area of the distal esophagus that is less distensible creating the ring-like structure on radiographic images.  Often, a patient is asked to swallow a substance like a marshmallow or a barium tablet to assess the diameter of the ring. This is often followed by an endoscopy to evaluate the ring, and then treat patients with symptoms. If the finding is incidental and the patient has no symptoms, treatment is not necessary until symptoms occur. However, endoscopy is still recommended to rule out other causes of strictures, especially esophageal malignancy. Biopsies should be performed if there is an irregular z-line at the gastroesophageal junction to assess for Barrett’s esophagus. Biopsies of the ring can be done as a treatment method as well.[10][11]

Treatment / Management

The goal of treatment is to reduce the diameter of the ring to allow unobstructed passage through the esophagus. Breaking the ring most often does this. Methods of doing so include dilation and/or biopsies of the ring with a biopsy forceps.

Dilation can be done with bougies or pneumonic balloons. Bougies can be used with a  guide wire (Savory dilators), without a guide wire (Maloney dilators), or with a pneumonic balloon dilator. Dilation with a bougie is done without direct visualization of the esophagus, but guidewire placement is done with direct visualization during endoscopy showing the path of the dilator. The pneumonic balloon dilators allow dilation with direct visualization. Fluoroscopy can be used as well to assist with dilation.

There has been evidence that doing four quadrant biopsies with a jumbo forceps will obliterate a Schatzki ring as well. This allows direct visualization of the treatment since it is done during an endoscopy. The whole ring is not broken with biopsies; therefore, there is some concern that the residual tissue may lead to recurrence, a concern that is being studied further.

Often patients are on some type of acid-reducing medication like a proton pump inhibitor (PPI) especially if they have mechanical obliteration of the ring with dilation or biopsy forceps. There is evidence that PPI along with dilation is safe and effective. The effect of PPI alone has been looked at as well in patients with average ring diameters of around 10 mm and can be followed with a barium-pill esophagram reducing the need for procedures and risks of dilation. Duration of treatment is on average 10 months, and the initial study only had nine participants; however, treatment is a consideration for populations of patients that are at high risk for procedures or dilations.

Differential Diagnosis

Differential diagnosis of Schatzki ring includes other causes of dysphagia, which can be extensive. Important differentials to keep in mind are eosinophilic esophagitis, reflux esophagitis, esophageal strictures other than Schatzki ring, extrinsic esophageal compression, motility disorders, and malignancy. If in combination with chest pain, then clinicians need to consider esophageal infections like candida esophagitis, pill esophagitis, radiation-induced esophagitis or stricture, or esophageal rupture especially if the symptoms are acute.

The timing of symptoms is important if there is more progressive dysphagia of solids to eventual liquids. This is concerning for worsening obstruction, and clinicians should have a high suspicion for malignancy. With such an extensive differential, any new-onset dysphagia should be evaluated further, especially to rule out more concerning causes like a malignancy.

Prognosis

Schatzki ring is a benign stricture and when symptomatic can be effectively treated. The patient often does well, and symptoms improve after treatment. Recurrence does occur with rates up to 64% in the first 2 years, hence requiring repeat dilation.

Enhancing Healthcare Team Outcomes

Schatzki ring is managed by dilatation or biopsies. The condition is often managed by the gastroemterologist. However, follow up is necessary by the nurse practitioner and primary care provider as recurrnence rates are high. Most patients need repeat dilatations.


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Schatzki Ring - Questions

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A patient presents with dysphagia and a diagnosis of a Schatzki ring is made. Which statement is correct?



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Which of the following is thought to account for the development of Schatzki ring?



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What is the usual presentation of a Schatzki ring?



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What test is best to confirm the presence of Schatzki ring?



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What is the treatment for a symptomatic Schatzki ring?



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A patient with a Schatzki ring underwent recent dilation but continues to have symptoms of dysphagia. What is the best next study?



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What is usually associated with a Schatzki ring?



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What pathology is most often associated with the upper endoscopy image seen below?

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  • Image 7047 Not availableImage 7047 Not available
    Image courtesy S Bhimji MD
Attributed To: Image courtesy S Bhimji MD



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Schatzki Ring - References

References

Ashraf HH,Palmer J,Dalton HR,Waters C,Luff T,Strugnell M,Murray IA, Can patients determine the level of their dysphagia? World journal of gastroenterology. 2017 Feb 14;     [PubMed]
Hossain SM,de Caestecker J, Acute oesophageal symptoms. Clinical medicine (London, England). 2015 Oct;     [PubMed]
Novak SH,Shortsleeve MJ,Kantrowitz PA, Effective Treatment of Symptomatic Lower Esophageal (Schatzki) Rings With Acid Suppression Therapy: Confirmed on Barium Esophagography. AJR. American journal of roentgenology. 2015 Dec;     [PubMed]
Levin MD,Mendel'son G, [Schatzki ring as a symptom of gastroesophageal reflux disease]. Vestnik rentgenologii i radiologii. 2015 Jan-Feb;     [PubMed]
Patel B,Han E,Swan K, Richard Schatzki: a familiar ring. AJR. American journal of roentgenology. 2013 Nov;     [PubMed]
Gonzalez A,Sullivan MF,Bonder A,Allison HV,Bonis PA,Guelrud M, Obliteration of symptomatic Schatzki rings with jumbo biopsy forceps (with video). Diseases of the esophagus : official journal of the International Society for Diseases of the Esophagus. 2014 Sep-Oct;     [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]
Towbin AJ,Diniz LO, Schatzki ring in pediatric and young adult patients. Pediatric radiology. 2012 Dec;     [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]
Gawrieh S,Carroll T,Hogan WJ,Soergel KH,Shaker R, Swallow syncope in association with Schatzki ring and hypertensive esophageal peristalsis: report of three cases and review of the literature. Dysphagia. 2005 Fall;     [PubMed]
Johnson AC,Lester PD,Johnson S,Sudarsanam D,Dunn D, Esophagogastric ring: why and when we see it, and what it implies: a radiologic-pathologic correlation. Southern medical journal. 1992 Oct;     [PubMed]

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