Schatzki Ring

A thin (2 to 4 mm), smooth mucosal ring at the squamocolumnar junction of the distal oesophagus, found just above a hiatus hernia, that narrows the lumen and causes intermittent solid-food dysphagia.

• Found in about 6 to 14% of barium swallows and in about 5 to 15% of patients having upper endoscopy; most are asymptomatic, and symptoms usually occur when the lumen diameter is less than 13 mm.
• Associations: hiatus hernia (almost always), gastro-oesophageal reflux, and eosinophilic oesophagitis (found in about 10 to 30% of patients with a ring and recurrent impaction).
• Mechanism: a mucosal fold of the junction with submucosal fibrosis (from reflux or inflammation).
• It is the commonest cause of intermittent, non-progressive dysphagia to solids in adults (the "steakhouse syndrome", from food impaction after meat).

Episodic dysphagia to solids (especially meat and bread) with a feeling of food sticking at the lower sternum; liquids pass easily; symptoms are non-progressive and occur at intervals of weeks to months.

• Acute food bolus impaction after a large mouthful, drooling, retrosternal pain, and relief after vomiting or regurgitation.
• Heartburn and regurgitation (reflux) in many patients; no weight loss.
• Differential diagnosis: peptic stricture, oesophageal web, eosinophilic oesophagitis, achalasia, oesophageal cancer, muscular A ring, motility disorder, extrinsic compression.
• Complications: recurrent food impaction (about 25% have recurrent episodes), aspiration, mucosal laceration, rarely perforation after forceful vomiting or push.

Barium swallow with a distended oesophagus is the best radiological test: a full-column barium swallow with the patient prone and a Valsalva manoeuvre, to show a thin symmetrical ring above a hiatus hernia; a 13 mm barium tablet or marshmallow given with the swallow detects functional narrowing.

• Upper endoscopy: a thin ring at the squamocolumnar junction (often missed if the oesophagus is not fully distended and when the hiatus hernia is not examined by retroflexion); measure the ring diameter by passing the endoscope (a 9 to 11 mm scope that resists passage indicates a diameter of less than 13 mm).
• Biopsies from the proximal and distal oesophagus (at least six, from two levels) to exclude eosinophilic oesophagitis, and of the gastro-oesophageal junction to look for Barrett oesophagus.
• High-resolution manometry if the diagnosis is uncertain or achalasia is suspected; pH monitoring for refractory reflux.

Dilate the ring, control reflux, treat eosinophilic oesophagitis when present, and counsel on eating.

• Diet and behaviour: small bites, chew thoroughly, eat slowly, drink with meals, cut meat finely, and avoid alcohol with meals.
• Acid suppression: omeprazole 20 to 40 mg daily (or 40 mg twice daily if eosinophilic oesophagitis is suspected or reflux is severe); long-term maintenance at the lowest effective dose reduces recurrence of the ring after dilatation.
• Dilatation (the definitive treatment for symptoms): bougie (Savary) or balloon dilatation to 16 to 20 mm (an aim of 18 to 20 mm gives the best result; one session may be enough, progressing by 1 to 2 mm steps); relief in over 90%; recurrence in about 30 to 70% within 1 to 2 years, which needs repeat dilatation at intervals of months to years.
• Ring disruption for resistant or recurrent rings: radial incision with a needle-knife or electrosurgical cutting in 3 to 4 quadrants, or a single-session biopsy forceps (cold forceps) disruption, followed by omeprazole 40 mg daily; longer symptom-free intervals.
• Eosinophilic oesophagitis: fluticasone propionate 880 micrograms twice daily swallowed or budesonide orodispersible tablet 1 mg twice daily for 8 to 12 weeks, then maintenance; dietary elimination; dupilumab 300 mg SC weekly for refractory disease.
• Acute food impaction: sit upright, suction secretions, glucagon 1 mg IV may be tried, endoscopic removal within 24 hours (emergency if saliva cannot be swallowed), by pushing the bolus into the stomach if the lumen is open or by retrieving it with a net or snare, followed by dilatation after a delay of days if the mucosa is torn.
• Surgery: antireflux surgery or hiatal repair is reserved for reflux refractory to drugs; resection is not needed.
• Special groups: children (rare; consider eosinophilic oesophagitis); pregnancy (omeprazole 20 mg daily, avoid dilatation unless essential, endoscopy for impaction is safe); elderly (check dentures, assess for stricture and cancer); renal impairment (no dose changes for omeprazole); anticoagulated patients (balloon dilatation is acceptable, hold the anticoagulant for incision).
• Red flags: unable to swallow saliva, chest pain after dilatation, fever, subcutaneous emphysema, progressive dysphagia, weight loss, anaemia.
• Follow-up: review at 4 to 8 weeks; repeat dilatation when dysphagia recurs; endoscopy with biopsies after 8 weeks of omeprazole for eosinophilic oesophagitis; surveillance for Barrett oesophagus if found.