Can esophagitis cause a Schatzki ring?

Relationship Between Esophagitis and Schatzki Ring

Yes, esophagitis can cause a Schatzki ring, as there is a strong association between gastroesophageal reflux disease (GORD), resulting esophagitis, and the development of Schatzki rings. 1, 2

Pathophysiology and Association

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 side covered by gastric mucosa
• Found in 6-14% of barium swallow examinations 2

The relationship between esophagitis and Schatzki rings is supported by several key observations:

• Schatzki rings are strongly associated with gastroesophageal reflux disease (GORD) 1, 2
• The effectiveness of PPI therapy in treating and preventing recurrence of Schatzki rings supports the causative role of acid reflux and resulting esophagitis 1
• In clinical studies, symptoms of esophagitis were present in the majority of patients with lower esophageal rings 3

Diagnostic Considerations

When evaluating a patient with suspected Schatzki ring:

• Consider obtaining distal, mid, and proximal esophageal biopsies to rule out eosinophilic esophagitis, which can present similarly 1, 2
• Assess for symptoms of GORD, as they frequently coexist with Schatzki rings 4
• Dysphagia typically occurs with ring diameters ≤13 mm and rarely with diameters >20 mm ("Schatzki's rule") 1, 2

Treatment Approach

For symptomatic Schatzki rings:

1. First-line treatment: Endoscopic dilatation to 16-20 mm followed by PPI therapy 1, 2

   • Single dilatation session is often sufficient
   • Target relatively large diameter (16-20 mm)

2. PPI therapy is essential:

   • Reduces risk of relapse of Schatzki ring 1
   • Can be effective as standalone treatment in some cases 5
   • Significantly improves ring lumen diameter (median increase from 10mm to 15mm) 5

3. For recurrent cases:

   • Consider electrosurgical incision as an effective alternative to repeated dilatation 1, 2
   • Provides longer dysphagia-free intervals compared to repeated bougienage 2

Important Clinical Considerations

• Do not offer dilatation for asymptomatic Schatzki rings incidentally discovered on diagnostic endoscopy or contrast studies 1
• PPI therapy is superior to H2 receptor antagonists, which are ineffective in reducing the need for repeat dilatation 1
• Dysphagia in patients with reflux may result from oesophagitis rather than stricture, and symptoms may improve with healing of oesophagitis using PPI 1
• Patients should be instructed in slow and careful mastication to reduce symptoms 4

Treatment Outcomes

With appropriate treatment:

• PPI therapy alone can increase ring diameter from a median of 10mm to 15mm 5
• Long-term PPI therapy significantly reduces the risk of relapse for up to 48 months 2
• Combination of dilatation and PPI therapy provides the most durable symptom relief 1, 2

The strong association between GORD, esophagitis, and Schatzki rings, combined with the effectiveness of acid suppression therapy, strongly supports the causal relationship between esophagitis and the development of Schatzki rings.