What is the diagnosis and treatment for Schatzki (esophageal) rings?

Diagnosis and Treatment of Schatzki Rings

For symptomatic Schatzki rings, treatment should include a single dilatation session to 16-20 mm followed by long-term PPI therapy, which significantly reduces the risk of relapse compared to placebo. 1

Diagnosis

• Schatzki's ring is an annular constriction at the gastroesophageal mucosal junction, covered proximally by squamous epithelium and distally by gastric mucosa 1
• Occurs in 6-14% of barium swallow examinations and is often asymptomatic 1
• Best diagnosed with a combination of history and carefully performed barium esophagram with solid bolus challenge 2
• "Schatzki's rule" states that dysphagia is usual with ring diameters ≤13 mm, rarely occurs if diameter exceeds 20 mm, with a "grey area" between 13-20 mm where symptoms are less consistently observed 1
• Schatzki's ring may not be visible during endoscopy unless the gastroesophageal junction is adequately distended by air insufflation 1
• Consider excluding eosinophilic esophagitis by obtaining distal, mid and proximal esophageal biopsies in symptomatic patients 1

Clinical Presentation

• Common cause of intermittent dysphagia for solids and food bolus obstruction 1
• Associated with gastroesophageal reflux disease (GERD) and eosinophilic esophagitis 1
• Patients may present with recurrent episodes of food impaction or progressive difficulty swallowing solid foods 2

Treatment Algorithm

First-line Treatment

• Do not offer dilatation for asymptomatic Schatzki's rings incidentally discovered on diagnostic endoscopy or contrast studies 1
• For symptomatic patients, offer a single dilatation session using graded dilatation to a relatively large diameter (16-20 mm) 1
• Dilatation therapy is directed toward achieving rupture of the ring, therefore larger calibre dilators may be needed 1
• Prescribe PPI therapy (e.g., omeprazole 20 mg twice daily) after dilatation, as this significantly reduces the risk of relapse 1, 3
• Some patients with dysphagia due to Schatzki's ring may be relieved by PPI therapy alone without the need for dilatation 1

Alternative/Second-line Treatments

• Electrosurgical incision of the ring is at least as effective as a single large calibre dilatation in relieving dysphagia 1
• Consider electrosurgical incision for patients with recurrence after a course of bougienage, as incision may lead to longer remission of dysphagia 1, 4
• Complete Schatzki ring obliteration with jumbo cold biopsy forceps has been shown to be safe and effective in a small feasibility study 3
• Four-quadrant biopsy of Schatzki's ring has demonstrated similar efficacy to Maloney dilation with a potentially superior cost/safety profile 5

Long-term Management

• Long-term PPI therapy (omeprazole 20 mg/day) significantly reduces the risk of relapse compared with placebo at up to 48 months of follow-up 1
• Offer PPI therapy rather than H2 receptor antagonists, which are ineffective in reducing the need for repeat dilatation 1
• Instruct patients in slow and careful mastication to reduce risk of food impaction 2
• Monitor for recurrence of dysphagia, as some patients may require repeated interventions 6

Complications and Precautions

• Perforation is a potential risk with any esophageal dilatation procedure, though the risk is lower with Schatzki rings compared to other esophageal strictures 1
• Consider performing a water-soluble contrast swallow after dilatation to screen for perforation, though this is not essential 1
• Untreated GERD may worsen dysphagia associated with Schatzki rings 2

Special Considerations

• Patients with smaller ring diameter (≤13 mm) are more likely to be symptomatic and require intervention 1
• For patients with recurrent symptoms despite standard therapy, consider alternative approaches such as electrosurgical incision or complete ring obliteration with jumbo biopsy forceps 3, 4