How should I urgently manage an 85-year-old patient with chronic gastro‑esophageal reflux disease on pantoprazole and a known Schatzki (lower esophageal) ring who now presents with an esophageal blockage?

Urgent Management of Esophageal Food Bolus Obstruction in an Elderly Patient with Schatzki Ring

This patient requires urgent endoscopy for food bolus removal, followed by esophageal dilation to 16-20 mm diameter and continuation of high-dose PPI therapy to prevent recurrence.

Immediate Management

Urgent Endoscopic Intervention

• Arrange urgent upper endoscopy for food bolus removal as this represents an acute esophageal obstruction requiring prompt intervention 1
• During the same endoscopic session, perform graded dilation to a relatively large diameter of 16-20 mm to rupture the Schatzki ring and prevent future episodes 1, 2
• The goal of dilation for Schatzki rings is to achieve rupture of the ring, which requires larger caliber dilators than other stricture types 1, 2

Exclude Eosinophilic Esophagitis

• Obtain esophageal biopsies from distal, mid, and proximal locations during endoscopy to exclude eosinophilic esophagitis, which is associated with Schatzki rings even without other mucosal abnormalities 1, 2
• This is particularly important as eosinophilic esophagitis can present with circular rings mimicking Schatzki rings and requires different management 2

Post-Procedure Management

Optimize PPI Therapy

• Continue or intensify pantoprazole therapy after dilation, as PPI therapy significantly reduces the risk of Schatzki ring relapse at up to 48 months follow-up 1, 2
• The patient is already on pantoprazole (Pantoloc), but ensure adequate dosing (typically 40 mg daily) 1, 2
• PPIs are superior to H2 receptor antagonists for preventing recurrence and are strongly recommended over alternatives 1

Monitor for Complications

• Consider water-soluble contrast swallow after dilation to screen for perforation, though this is not essential 1
• Watch for signs of perforation including persistent pain, breathlessness, fever, or tachycardia 3
• Provide the patient with contact information for urgent issues post-procedure 3

Alternative Approach if Dilation Fails

Electrosurgical Incision

• Consider electrosurgical incision of the ring as an equally effective alternative to dilation, particularly if symptoms recur after initial bougienage 1, 2
• Evidence suggests electrosurgical incision may lead to longer remission periods than repeat dilation 1

Long-Term Prevention Strategy

Maintenance Therapy

• Prescribe long-term PPI therapy (omeprazole 20 mg/day or equivalent pantoprazole dose) as this significantly reduces relapse risk compared to placebo 1, 2
• Some patients with Schatzki ring-related dysphagia may respond to PPI therapy alone without requiring dilation, though this patient clearly needs immediate intervention for the acute obstruction 1, 2

Patient Education

• Instruct the patient on slow and careful mastication to prevent future food bolus impactions 4
• Explain that Schatzki rings are associated with GERD, and controlling reflux is essential for preventing recurrence 1, 4, 5

Important Caveats

• Age consideration: At 85 years old, ensure the patient can tolerate endoscopy and consider comorbidities that may increase procedural risk 1
• Single session approach: A single dilation session to adequate diameter (16-20 mm) is preferred over multiple smaller dilations for Schatzki rings 1, 2
• Perforation risk: While perforation is possible with any esophageal dilation, the risk is lower with Schatzki rings compared to other stricture types 2