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

  A-Ring = Lower esophageal muscular ring Mostly asymptomatic. Symptoms if present : Dysphagia for both solids and liquids in absence of food impactions. [mediconotebook.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]

  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]

  Schatzki rings are often asymptomatic. Typically, symptoms occur when a Schatzki ring is of a small diameter. [healthline.com]

  Depending on its luminal diameter, an esophageal B-ring may be symptomatic or asymptomatic 4 : 13-20 mm: sometimes symptomatic >20 mm: rarely symptomatic When it is symptomatic, it is termed a "Schatzki ring". [radiopaedia.org]

• Pathologist

  This is a little curious, since pathologists are really only endoscopists looking down rigid instruments, but perhaps our trust in their reports speaks to the quality of their training and experience. [gastrohep.com]

  Once a biopsy is performed, the pathologist can determine if there is esophageal cancer, and whether it is adenocarcinoma or squamous cell carcinoma. [oncolink.org]

• Chronic Cough

  RELATIONSHIP BETWEEN GERD AND COUGH Kulkarni said, “There is a dual relationship between GERD and chronic cough; GERD can cause cough and chronic cough could also lead to GERD. [economictimes.indiatimes.com]

  It is usually caused by forceful vomiting or chronic coughing. Symptoms may include bloody stools or vomiting of blood. Esophageal varices: Esophageal varices are enlarged veins in the walls of the esophagus that balloon outward. [herringmd.com]

  Additionally, some people complain of chronic cough from the reflux due to irritation of the voice box from the acid reflux. [oncolink.org]

• Dysphagia

  Lower esophageal ring may be managed satisfactorily through oral dilation, resulting in relief of dysphagia. [ncbi.nlm.nih.gov]

  Typically, evaluation of dysphagia begins with upper endoscopy, which should show a ring large enough to cause symptoms. If the distal esophagus is adequately distended, barium x-rays usually also show the ring. [msdmanuals.com]

• Intermittent Dysphagia

  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]

  dysphagia associated with solids amongst the adult population. [symptoma.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]

  They include: difficulty swallowing (dysphagia), which can be painful a lump or feeling of fullness in the throat chest pain heartburn regurgitation of undigested food or liquids (including when asleep) coughing or choking (due to regurgitation of food [mydr.com.au]

• Odynophagia

  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]

  Other risks reported after anti-reflux surgery procedures include bloating, nausea, dysphagia (difficulty swallowing), odynophagia (painful swallowing), retching, and vomiting. [toraxmedical.com]

  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]

• Flatulence

  The problems that may occur after surgical procedures include difficulty in swallowing, flatulence or gas, bloating and difficulty in burping. [news-medical.net]

  […] failure, device migration (device does not appear to be at implant site), diarrhea, dyspepsia (indigestion), dysphagia (difficulty swallowing), early satiety (feeling full after eating a small amount of food), esophageal spasms, esophageal stricture, flatulence [toraxmedical.com]

  Long term side effects are vitamin B12 deficiency, rash, constipation, itch, anxiety, flatulence, depression, erythema, constipation, acute interstitial nephritis and pancreatitis. [medlicker.com]

  Severe dysphagia requiring endoscopic dilation was more frequent after MSA (50% of cases), while there was a trend for a reduction in bloating, flatulence, and diarrhea in this small retrospective study. [bcidaho.com]

• 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]

  Follow-up treatment Balloon dilation and surgery can both cause side effects such as acid reflux and heartburn and chest pain. [nhs.uk]

  Symptoms of impacted food in the throat include chest pain, difficulty swallowing, decreased saliva and secretion production. [medicinenet.com]

  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]

• Confusion

  They should not be confused with A-rings, which are found a few centimeters proximal to the B-ring esophageal webs, which are lined on both sides by esophageal mucosa 6-8 Associations More than half of patients will have an associated esophageal condition [radiopaedia.org]

  Complications § Large incarcerated hiatal hernias may slowly weep blood so that patients present with iron deficiency anemia, rather than reflux symptoms § Peptic esophagitis from reflux § Discrete marginal ulcers § Strictures o The terminology can be confusing [learningradiology.com]

  Mucosal biopsies taken from a hernia pouch have resulted in overdiagnosis and confusion in surveillance reports. [hon.ch]

  ANOMALIES OF ESOPHAGEAL LUMEN RINGS AND WEBS The definition of webs and rings is confusing because the terms have been used interchangeably. [clevelandclinicmeded.com]

  (It is confusing, as it has nothing to do with the heart!) [patient.info]

• Forgetful

  Read More 4 Easy Ways to Keep Your Eyes Healthy This Summer As it begins to warm up outside, don’t forget how damaging the sun can be for your eyes. The same way UV rays... Read More [utmedicalcenter.org]

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].

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.

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.

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:

• Gastroesophageal reflux disease (GERD)
• Inflammation caused by the ingestion of pills
• Graft versus host disease
• Iron deficiency anemia
• Caustic ingestion
• Mediastinal radiation therapy
• Celiac sprue
• Autoimmune skin diseases such as benign mucous membrane pemphigoid and epidermolysis bullosa dystrophica

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.

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.

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

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].

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.

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.