Treatment of Schatzki Ring
For symptomatic Schatzki rings causing dysphagia, perform a single session of graded esophageal dilation to 16-20 mm diameter, followed by long-term proton pump inhibitor therapy to prevent recurrence. 1, 2
Initial Assessment
Do not treat asymptomatic Schatzki rings discovered incidentally on endoscopy or barium studies performed for unrelated indications 1
Obtain esophageal biopsies from distal, mid, and proximal locations in all symptomatic patients to exclude eosinophilic esophagitis, which can mimic Schatzki rings 1, 2
Understand that dysphagia typically occurs with ring diameters ≤13 mm, rarely with diameters >20 mm, with variable symptoms between 13-20 mm ("Schatzki's rule") 2
Primary Treatment Approach
Endoscopic Dilation
Perform graded dilation to a relatively large diameter of 16-20 mm in a single session to achieve rupture of the ring 1, 2
Use either balloon or bougie dilators based on local expertise and clinician preference 1
Larger caliber dilators are necessary because the therapeutic goal is ring rupture, not just stretching 2
Consider fluoroscopic guidance for complex cases, though endoscopic control is equally acceptable 1
Post-Dilation Medical Therapy
Prescribe proton pump inhibitor therapy (e.g., omeprazole 20 mg twice daily) after dilation as this significantly reduces relapse risk 1, 2
Continue long-term PPI therapy (omeprazole 20 mg daily) to maintain symptom relief, with proven efficacy up to 48 months 2
Do not use H2 receptor antagonists, as they are ineffective in preventing recurrence 1, 2
Some patients may respond to PPI therapy alone without requiring dilation 2
Alternative Treatment Options
Electrosurgical Incision
Consider electrosurgical incision as an equally effective alternative to large-caliber dilation for relieving dysphagia 1
This approach is particularly useful for recurrent rings after previous dilations 3
Endoscopic incision provides longer dysphagia-free intervals compared to repeated bougienage (mean 17 months vs. 5 months) 3
Other Endoscopic Techniques
Complete ring obliteration using jumbo cold biopsy forceps (8-12 biopsies in four quadrants) is safe and effective, with sustained improvement at mean follow-up of 379 days 4
Four-quadrant biopsy technique shows equivalent efficacy to 52-Fr Maloney dilation with superior patient tolerability and cost profile 5
Post-Procedure Management
Consider water-soluble contrast swallow after dilation to screen for perforation, though this is not mandatory 1
Monitor for complications including perforation (low risk with Schatzki rings compared to other strictures) 2
Expect 10-40% rate of symptomatic GERD or ulcerative esophagitis after treatment, reinforcing the need for PPI therapy 1
Common Pitfalls
Failing to obtain biopsies risks missing eosinophilic esophagitis, which requires different management and can present with similar circular rings 1, 2
Using inadequate dilation diameter (<16 mm) increases recurrence rates 1, 2
Omitting post-dilation PPI therapy significantly increases relapse risk 1, 2
The ring may not be visible endoscopically unless the gastroesophageal junction is adequately distended with air insufflation 2
Special Considerations
Schatzki rings are associated with hiatal hernias and gastroesophageal reflux disease 6, 7
In patients without proven reflux, chronic pill ingestion may contribute to ring formation and these patients may respond better to single dilation 7
Biphasic esophagram with prone single-contrast views is superior to endoscopy for detecting lower esophageal rings (95% vs. 76% detection rate) 2