What is the treatment for an esophagus ring?

Treatment of Esophageal Rings

For symptomatic Schatzki's rings, offer a single dilatation session using graded dilatation to a relatively large diameter (16-20 mm) followed by proton pump inhibitor therapy to reduce risk of relapse. 1, 2

Diagnosis and Classification

• Schatzki's ring is an annular constriction at the gastroesophageal mucosal junction, covered proximally by squamous epithelium and distally by gastric mucosa 2
• Occurs in 6-14% of barium swallow examinations and is often asymptomatic 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 2
• Consider excluding eosinophilic esophagitis by obtaining distal, mid and proximal esophageal biopsies in symptomatic patients 1, 2

Treatment Algorithm

First-line Treatment

• For symptomatic patients, perform a single dilatation session using graded dilatation to a relatively large diameter (16-20 mm) 1, 2
• Dilatation therapy is directed toward achieving rupture of the ring, therefore larger calibre dilators may be needed 2
• Do not offer dilatation for asymptomatic Schatzki's rings incidentally discovered on diagnostic endoscopy or contrast studies 1
• Prescribe PPI therapy after dilatation, as this significantly reduces the risk of relapse 1, 2

Alternative Treatment Options

• Electrosurgical incision is an effective alternative treatment to esophageal dilatation for relieving dysphagia related to Schatzki's ring 1, 3
• Some patients with dysphagia due to Schatzki's ring may be relieved by PPI therapy alone without the need for dilatation 2, 4
• Complete Schatzki ring obliteration with jumbo cold biopsy forceps has been shown to be safe and effective in small studies 5

Evidence for GERD Association and PPI Therapy

• Gastroesophageal reflux disease (GERD) is implicated in the pathogenesis of Schatzki's rings 6
• PPI therapy after dilatation significantly reduces the risk of relapse compared with placebo at up to 48 months of follow-up 2
• Offer PPI therapy rather than H2 receptor antagonists, which are ineffective in reducing the need for repeat dilatation 1
• A study demonstrated significant improvements in both ring lumen diameter and ability to pass a tablet through the esophagus with acid suppression medication alone 4

Complications and Follow-up

• Perforation is a potential risk with any esophageal dilatation procedure, though the risk is lower with Schatzki rings compared to other esophageal strictures 2
• Consider performing a water-soluble contrast swallow after dilatation to screen for perforation, though this is not essential 1
• Recurrence is common after traditional dilatation methods, requiring repeat procedures 3
• Long-term PPI therapy significantly reduces the risk of relapse 2

Special Considerations

• For patients with recurrent symptoms despite standard treatment, consider endoscopic incision which may provide a longer dysphagia-free interval compared to repeated bougienage 3
• Patients with smaller ring diameter (≤13 mm) are more likely to be symptomatic and require intervention 2