What is the best course of treatment for a patient with dysphagia and a sensation of something being stuck, who has an esophagram showing a mild hiatal (hiatus) hernia, narrowed esophagus with a Schatzki B-ring, mucosal irregularity, spontaneous gastroesophageal reflux, and a prominent cricopharyngeus muscle?

From the Guidelines

The best course of treatment for this patient with dysphagia and a sensation of something being stuck is a multi-faceted approach including proton pump inhibitor (PPI) therapy and mechanical dilation of the Schatzki ring. This approach is based on the most recent and highest quality evidence from the UK guidelines on oesophageal dilatation in clinical practice 1. The patient's esophagram shows a narrowed esophagus with a Schatzki B-ring, which is a common cause of intermittent dysphagia for solids and food bolus obstruction, especially with ring diameters of ≤ 13 mm 1. Given the patient's symptoms and the 12 mm barium tablet lodging in the location of the Schatzki ring, initial management should include a PPI such as omeprazole 40mg or esomeprazole 40mg daily, taken 30 minutes before breakfast for at least 8 weeks, combined with mechanical dilation of the Schatzki ring to a diameter of 16-20 mm 1. Following dilation, the patient should continue PPI therapy indefinitely to prevent recurrence of the ring and manage the gastroesophageal reflux, as this reduces the risk of relapse of Schatzki’s ring 1. Additionally, lifestyle modifications such as elevation of the head of the bed, avoiding meals within 3 hours of bedtime, weight loss if overweight, and avoiding trigger foods should be recommended. The prominent cricopharyngeus muscle may benefit from swallowing therapy with a speech pathologist to improve coordination. Electrosurgical incision is also an effective alternative treatment to oesophageal dilatation for relieving dysphagia related to Schatzki’s ring, and can be considered if necessary 1. This comprehensive approach addresses both the mechanical obstruction from the Schatzki ring and the underlying reflux disease that likely contributed to the esophageal changes. Key points to consider in the treatment plan include:

• PPI therapy to reduce acid production and allow esophageal mucosa healing
• Mechanical dilation of the Schatzki ring to directly address the narrowing
• Lifestyle modifications to manage reflux disease
• Swallowing therapy for the prominent cricopharyngeus muscle
• Consideration of electrosurgical incision as an alternative treatment.

From the Research

Diagnosis and Treatment Options

The patient's esophagram shows a mild hiatal hernia, narrowed esophagus with a Schatzki B-ring, mucosal irregularity, spontaneous gastroesophageal reflux, and a prominent cricopharyngeus muscle. The best course of treatment for this patient can be determined by considering the following:

• The Schatzki B-ring is a common cause of solid food dysphagia, and its pathogenesis may be related to gastroesophageal reflux disease (GERD) 2.
• The patient's symptoms can be treated with instruction in slow and careful mastication, and bougienage is the main form of treatment for Schatzki's ring 2.
• Pneumatic dilation, electrosurgical techniques, or surgical repair may be required for selected patients 2.
• The prominent cricopharyngeus muscle may be contributing to the patient's dysphagia, and botulinum toxin injections into the cricopharyngeus muscle have been shown to be effective in treating cricopharyngeal dysphagia 3.

Treatment of Schatzki's Ring

The treatment of Schatzki's ring typically involves:

• Bougienage, which is generally effective but may require repeated sessions 4.
• Pneumatic dilation, which can be used to treat patients who do not respond to bougienage 2.
• Treatment of GERD, which is important to prevent symptomatic recurrence of the ring 4.
• Single-session graded esophageal dilation with large caliber Savary dilators without fluoroscopic guidance can be safely used for symptomatic relief in patients with lower esophageal (Schatzki's) rings 4.

Considerations for Treatment

When considering treatment options, the following should be taken into account:

• The presence of GERD, which should be treated if present 2, 4.
• The patient's history of chronic ingestion of drugs known to be damaging to the esophageal mucosa, which may be related to the development of Schatzki's ring 5.
• The patient's response to initial treatment, as some patients may require repeated sessions or alternative treatments 4, 5.