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Lower Esophageal Ring

Esophagogastric Ring Syndrome

A lower esophageal ring is defined as a narrowing of the esophagus at the squamocolumnar junction.


Presentation

Lower esophageal rings cause specific symptoms in affected patients, none of which, however, are pathognomonic. Symptoms include dysphagia associated with solid foods and especially bread and meat; the episodes are periodic, do not exacerbate with time and last for a short period of time. Solid foods may be regurgitated or forced down with the aid of a liquid drink. The clinical picture may be complicated with symptoms associated with gastroesophageal reflux disease, such as heartburn.

Asymptomatic
  • One-third of the symptomatic patients and one-fourth of the asymptomatic patients demonstrated increasing stenosis of their rings compared to the initial measurements.[hon.ch]
  • A-Ring Lower esophageal muscular ring Mostly asymptomatic. Symptoms if present : Dysphagia for both solids and liquids in absence of food impactions .[mediconotebook.com]
  • In some individuals, the condition may be asymptomatic and discovered only incidentally, while the healthcare provider examines the individual for other medical conditions.[dovemed.com]
  • Symptoms Patients with a Schatzki’s ring are usually asymptomatic. Any symptoms are directly associated with the extent of narrowing caused by the ring.[memorialhermann.org]
  • Schatzki rings are often asymptomatic. Typically, symptoms occur when a Schatzki ring is of a small diameter.[healthline.com]
Intermittent Dysphagia
  • dysphagia associated with solids amongst the adult population.[symptoma.com]
  • These rings cause intermittent dysphagia for solids. Symptoms can begin at any age but usually do not begin until after age 25. The swallowing difficulty comes and goes and is especially aggravated by meat and dry bread.[msdmanuals.com]
  • Most commonly it presents as intermittent dysphagia, especially to solid food. A history of food impaction is also very common. Dysphagia is more common in patients with an associated motility disorder.[radiopaedia.org]
  • Patients classically present with intermittent dysphagia to solids. Diagnosis is made by endoscopy or a barium esophagram. Gastroesophageal reflux disease has been suggested as an etiology. It can usually be treated by passing a large dilator.[journals.lww.com]
Choking
  • Oesophageal symptoms included dysphagia (27%), reflux (6%), choking (3%) and failure to thrive (3%).[ncbi.nlm.nih.gov]
  • Other symptoms include: bringing back up undigested food choking and coughing fits heartburn chest pain repeated chest infections drooling of vomit or saliva gradual but significant weight loss Symptoms of achalasia may start at any time of life.[nhs.uk]
  • Benign esophageal stricture causes difficulties in swallowing food, saliva or liquids and increases the risk of choking. It impairs the passage of food or liquid through the esophagus with a sensation of fullness or pressure in the chest.[medlicker.com]
  • You choke, rather than gag, when food goes down the trachea, a problem with a ready antidote: the Heimlich maneuver. But you can’t Heimlich something in your food tube. You either have to coax it into your stomach or—worst case—regurgitate it.[texasmonthly.com]
Odynophagia
  • Other risks reported after anti-reflux surgery procedures include bloating, nausea, dysphagia (difficulty swallowing), odynophagia (painful swallowing), retching, and vomiting.[toraxmedical.com]
  • HSV Esophagitis 14 year old boy with odynophagia, dysphagia and chest pain Normal Esophagus Endoscopic photograph of a normal esophagus taken from a 8 yo.[naspghan.org]
  • SIGNS AND SYMPTOMS Mucosal injury may be asymptomatic or may manifest by dysphagia, odynophagia or chest pain.[clevelandclinicmeded.com]
  • Adverse events of the LINX Reflux Management System may include dysphagia or odynophagia. The device can be removed by a laparoscopic procedure if severe adverse events occur or if magnetic resonance imaging (MRI) is needed for another condition.[bcidaho.com]
Progressive Dysphagia
  • The symptoms may be either episodic aphagia or progressive dysphagia, and the severity of symptoms is related to the diameter of the ring.[ncbi.nlm.nih.gov]
  • In most cases, LER presents as episodic or progressive dysphagia although, in the extreme, it can progress into a total obstruction of the esophagus.[google.la]
  • Worsening strictures may cause progressive dysphagia - from hard food, such as meat, to sloppy food like porridge, to liquids - so ask about progression of symptoms and the time span.[patient.info]
Aphagia
  • The symptoms may be either episodic aphagia or progressive dysphagia, and the severity of symptoms is related to the diameter of the ring.[ncbi.nlm.nih.gov]
Chest Pain
  • No major complication occurred, although one patient had transient chest pain. Subsequently, all patients have remained without symptoms at a mean follow-up of 36 months.[ncbi.nlm.nih.gov]
  • Symptoms Chest pain under the breastbone Difficulty swallowing Exams and Tests Tests that show the lower esophageal ring include: EGD (esophagogastroduodenoscopy) Upper GI (x-ray with barium) Treatment Treatment involves stretching the ring by passing[dxline.info]
  • Symptoms of impacted food in the throat include chest pain, difficulty swallowing, decreased saliva and secretion production.[medicinenet.com]
  • Follow-up treatment Balloon dilation and surgery can both cause side effects such as acid reflux and heartburn and chest pain.[nhs.uk]
  • Often large food boluses become impacted above the stenotic ring and patients describe episodes of severe chest pain or an uncomfortable sensation behind their lower sternum. However, not all lower esophageal rings are classified as Schatzki rings.[med-ed.virginia.edu]

Workup

The first step towards a successful diagnosis is a medical history. Patients tend to report symptoms such as dysphagia to solid foods and prior intake of gastroesophageal reflux-related medication that had no effect. A barium esophagram is used to further illustrate lesions such as webs or rings in the esophagus and an esophageal manometry can help to further evaluate a patient if suspicious findings have been detected. A set of specific criteria has been published for the accurate diagnosis of a lower esophageal ring [8].

Treatment

As far as conservative methods are concerned, patients are advised to avoid eating quickly. The primary treatment of lower esophageal rings is the large-bore endoscopic dilation or bougienage, which has evinced excellent results within a short period of time following the procedure. Contraindications for the procedure are bullous disease, Zenker diverticulum, eosinophilic esophagitis and other diseases that increase the risk of perforation.

When dilation is contraindicated, unsuccessful or unavailable, surgical excision, electrocautery and resection with jumbo cold biopsy forceps can be performed [9]. In cases of patients who remain unresponsive to the treatments mentioned above, further evaluation should be sought.

Prognosis

The condition is associated with a good prognosis. Mild narrowing typically causes no symptoms, whereas most of the symptomatic patients are successfully treated with one or more sessions of dilations, rendering surgery a procedure that is rarely employed. No case of death linked to lower esophageal rings has ever been reported.

Etiology

Lower esophageal rings can occur as an inborn esophageal irregularity or present later in life. Acquired rings can develop as a result of the following conditions:

Epidemiology

Lower esophageal rings are frequently illustrated in barium radiographs carried out for other diagnostic purposes at an average rate of 10% [3] [4] [5] [6] and constitute the predominant cause of intermittent dysphagia associated with solids amongst the adult population [7]. There is, however, inadequate scientific data in order for an accurate prevalence to exist.

Sex distribution
Age distribution

Pathophysiology

The pathogenetic background that underlies lower esophageal rings is not known. Most theories associate the phenomenon with inborn anomalies of esophageal structure, Gastroesophageal reflux disease, temporary shortenings of the esophagus or pill-related inflammation. Some researchers support that there is a connection between the diameter of the lumen and the development of Schatzki rings.

Prevention

Managing gastroesophageal reflux disease and anemia caused by iron deficiency may slightly contribute to the prevention of lower esophageal rings.

Summary

Lower esophageal rings are circular narrowings of the esophagus at its distal part, which is adjacent to the esophagogastric junction. They cause a complete or fractional obstruction of the esophageal lumen and are covered with squamous and/or gastric columnar epithelium.

They are otherwise referred to as Schatzki rings, as they were first described by Schatzki and Gary in 1953 [1]. Lower esophageal rings are diagnosed via a barium esophagram and treated with endoscopic dilation [2].

Patient Information

The esophagus is an elongated organ that connects the oral cavity with the stomach. It is covered by mucosa and its elasticity allows it to narrow or widen its diameter so that food can easily pass through.

Sometimes, circular strictures appear at the bottom of the esophagus, near its junction to the stomach. These are called lower esophageal rings or Schatzki rings. A person can be born with such an anomaly or develop it due to other conditions.

Schatzki rings cause difficulty in swallowing solid food. They are diagnosed with a barium esophagram and treated with a device that inflates when inserted in the area of the ring, so as to flatten the latter.

References

Article

  1. Schatzki R, Gary JE. Dysphagia due to diaphragm-like localized narrowing in the lower esophagus (Lower esophageal ring). Amer J Roentgenol. 1953; 70: 911-922.
  2. Templeton FE. X-Ray Examination of the Stomach: A Description of the Roentgenologic Anatomy, Physiology and Pathology of the Esophagus, Stomach, and Duodenum. Chicago: University of Chicago Press; 1944: 106-112.
  3. Kramer P. Frequency of the asymptomatic lower esophageal contractile ring. N Engl J Med. 1956;254:692–694.
  4. Keyting WS, Baker GM, Mccarver RR, Daywitt AL. The lower esophagus. Am J Roentgenol Radium Ther Nucl Med. 1960;84:1070–1075.
  5. Goyal RK, Glancy JJ, Spiro HM. Lower esophageal ring. 1. N Engl J Med. 1970;282:1298–1305.
  6. Schatzki R, Gary JE. The lower esophageal ring. Am J Roentgenol Radium Ther Nucl Med. 1956;75:246–261.
  7. Schatzki R. The lower esophageal ring. long term follow-up of symptomatic and asymptomatic rings. Am J Roentgenol Radium Ther Nucl Med. 1963;90:805–810.
  8. Postlethwait RW, Sealy WC. Experiences with treatment of 59 patients of lower esophageal web. Ann Surg. 1967; 165: 786-796.
  9. Gonzalez A, Sullivan MF, Bonder A, Allison HV, Bonis PA, Guelrud M. Obliteration of symptomatic Schatzki rings with jumbo biopsy forceps (with video). Dis Esophagus. 2014;27(7):607-10.

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Last updated: 2019-07-11 20:57