How is a Schatzky ring typically managed?

Management of Schatzki Ring

Symptomatic Schatzki rings should be treated with a combination of endoscopic dilatation to 16-20 mm followed by long-term proton pump inhibitor (PPI) therapy to prevent recurrence. 1

Diagnosis and Clinical Presentation

Schatzki's ring is an annular constriction at the gastroesophageal junction characterized by:

• Located at the squamocolumnar junction (proximal side covered by squamous epithelium, distal by gastric mucosa)
• Common finding in 6-14% of barium swallow examinations
• Often causes intermittent dysphagia for solids and food bolus obstruction
• According to "Schatzki's rule," dysphagia is typically present with ring diameters ≤13 mm and rarely occurs with diameters >20 mm 1

Management Algorithm

Step 1: Determine if intervention is needed

• Asymptomatic rings: No dilatation needed for incidentally discovered asymptomatic Schatzki rings 1
• Symptomatic rings: Proceed with treatment if patient presents with dysphagia or food impaction

Step 2: Initial therapeutic approach

• First-line treatment options:
  • Endoscopic dilatation: Offer a single dilatation session using graded dilatation to a relatively large diameter (16-20 mm) 1
  • PPI therapy: May be effective as standalone treatment in some cases 2

Step 3: Post-dilatation management

• Initiate PPI therapy: Long-term PPI therapy (e.g., omeprazole 20 mg/day) significantly reduces the risk of relapse compared with placebo for up to 48 months 1

Step 4: Management of recurrent symptoms

• For recurrence after dilatation:
  • Electrosurgical incision: Consider as an effective alternative to repeated dilatation 1, 3
  • Repeat dilatation: May be needed for persistent symptoms
  • Biopsy excision: Complete ring obliteration with jumbo cold biopsy forceps has shown promising results in small studies 1, 4

Evidence-Based Considerations

Effectiveness of PPI Therapy

• PPI therapy after dilatation significantly reduces the risk of relapse of Schatzki's ring 1
• Recent research shows that acid suppression medication alone can be effective, with significant improvements in ring lumen diameter (median increase from 10mm to 15mm) and ability to pass food 2

Alternative Treatment Options

• Electrosurgical incision: At least as effective as single large calibre dilatation in randomized trials 1
  • Provides longer dysphagia-free intervals compared to repeated bougienage (17 months vs. 5 months) 3
• Biopsy excision: Complete obliteration with jumbo cold biopsy forceps was effective and safe in a small feasibility study of 10 patients, with improvement persisting during a mean follow-up of 379 days 4

Important Considerations and Caveats

• Rule out eosinophilic esophagitis: Consider obtaining distal, mid, and proximal esophageal biopsies in symptomatic Schatzki's ring to exclude eosinophilic esophagitis 1

• Association with GERD: Schatzki's ring is associated with gastroesophageal reflux, which may explain why PPI therapy reduces recurrence rates 1, 5

• Medication history: Some patients without proven reflux may have Schatzki's ring related to chronic ingestion of medications known to damage esophageal mucosa 5

• Response to treatment: Patients without reflux may respond better to a single dilatation (62%) compared to those with reflux (37%) 5

• Treatment selection: The therapeutic approach should consider the presence or absence of reflux, as this may influence treatment response and recurrence rates 1, 5