Oesophageal Ring

• Types of rings
  • A - normal smooth muscle contraction in the esophagus
  • B -  mucosal structure precisely at the squamocolumnar junction that is smooth and thin (≤5 mm in axial length). Owing to its location, a B ring is covered with squamous mucosa proximally and columnar epithelium distally
    • Esophageal rings are usually mucosal but in rare cases may be muscular due to hypertrophy of an A ring.
    • Schatzki ring, the most common type of esophageal ring, is a narrow mucosal B ring that is less than 12.5 mm in diameter
• Aetiology
  • Hiatus hernia 
    • Schatzki rings are almost always associated with a hiatal hernia. In a study of 167 patients with a Schatzki ring, a hiatal hernia was detected in 97 percent
      • Lies precisely at squamocolumnar mucosal GEJ
      • Does not have a component of true oesophageal muscle
    • Aetiology not understood
      • ? Persistent apposition of two mucosal layers & fibrosis of submucosa.
      • Almost always accompanied by a small hiatal hernia -? fibrosed proximal margin of sliding HH.
  • Eosinophilic oesophagitis
    • Schatzki rings have also been associated with eosinophilic esophagitis
    • However, more often patients with eosinophilic esophagitis have multiple proximal esophageal rings, long strictured segments, linear furrows in the mucosa, and eosinophilic abscesses that appear as white papules.
• Symptoms
  • Often asymptomatic
  • Episodic dysphagia (often large pieces of meat causing complete obstruction).
  • Often spontaneously passes after a few minutes
• Investigations
  • Barium swallow +/- endoscopy.
  • Endoscopy
    • Biospy ? eosinophilic esophagitis.
      • Dilation in patients with eosinophilic esophagitis is usually reserved for patients with rings who have not responded to medical therapy.
• Management
  • Endoscopic
    • Dilation - Large caliber bougie (≥50 French) or balloon dilator (18 to 20 mm)

Esophageal (Schatzki) ring seen on barium swallow