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A Schatzki ring or Schatzki-Gary ring is a ring of redundant mucosal or muscular tissue in the lower esophagus.Schatzki R, Gary JE. Dysphagia due to a diaphragm-like localized narrowing in the lower esophagus (lower esophageal ring). Am J Roentgenol Radium Ther Nucl Med. 1953 Dec;70(6):911-22. PMID 13104726 Patients with Schatzki rings can present with intermittent dysphagia or difficulty swallowing, or with frank obstruction of the esophagus.
Clinical presentation
Not all patients with Schatzki rings have symptoms. If they do, they usually come to the attention of physicians after developing episodic dysphagia to solid foods, particularly if the foodstuff is not chewed properly. This is oftentimes termed the steakhouse syndrome: during a meal, there is a bolus obstruction of the esophagus with some foodstuff, resulting in acute crushing chest pain and dysphagia. Patients usually are able to regurgitate or force through the food material, but may need immediate endoscopic treatment for removal of the bolus.Stadler J, Holscher AH, Feussner H, Dittler J, Siewert JR. The "steakhouse syndrome". Primary and definitive diagnosis and therapy. Surg Endosc. 1989;3(4):195-8. PMID 2623551 This involves urgent endoscopy to locate the area of the bolus obstruction, followed by the insertion of devices to either pull the foodstuff out of the esophagus, or push it into the stomach. The latter is usually done only with caution, or if the anatomy is already known. Endoscopic snares and forceps can be used for these purposes.
Diagnosis
Diagnosis of Schatzki rings is usually made through esophagogastroduodenoscopy or barium swallow. Endoscopy typically shows a ring within the lumen of the esophagus, and that may be of variable size. The ring is typically located within a few centimetres proximal to (that is, above) the gastro-esophageal junction.
Oftentimes endoscopies and barium swallows done for other indications show evidence of Schatzki rings,Pezzullo JC, Lewicki AM. Schatzki ring, statistically reexamined. Radiology. 2003 Sep;228(3):609-13. PMID 12869689 leading to the belief that many Schatzki rings may cause no symptoms.
Two varieties of Schatzki rings have been described. The original description by Schatzki and Gary was of a ring of fibrous tissue seen on autopsy; this is the far less common type of Schatzki ring. More commonly, the ring consists of mucosal tissue. Many hypotheses have been raised as to the cause of the Schatzki rings, and both congenital and acquired theories have been discussed in the literature.
Treatment
If asymptomatic, there is evidence that Schatzki rings do not progress to cause symptoms, and no treatment is suggested.
Symptomatic Schatzki rings may be treated with esophageal dilatation, either using rigid or balloon dilators. These have been found to be equally effective.Scolapio JS, Pasha TM, Gostout CJ, Mahoney DW, Zinsmeister AR, Ott BJ, Lindor KD. A randomized prospective study comparing rigid to balloon dilators for benign esophageal strictures and rings. Gastrointest Endosc. 1999 Jul;50(1):13-7
After treatment with dilatation or endoscopic management of a bolus obstruction, a short course of proton pump inhibitor therapy may be used.
Other associations
- Schatzki rings can be associated with swallowing syncope, a rare variety of syncope.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;20(4):273-7. PMID 16633871
- Schatzki rings are associated with a decreased incidence of Barrett's esophagus.Mitre MC, Katzka DA, Brensinger CM, Lewis JD, Mitre RJ, Ginsberg GG. Schatzki ring and Barrett's esophagus: do they occur together? Dig Dis Sci. 2004 May;49(5):770-3. PMID 15259497
See also
References
"Schatzki ring"