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.

• Inflammation

  Does inflammation cause the LER? Because there is frequently reflux and esophagitis associated with HH and consequently with rings, inflammation has been an attractive hypothesis as an explanation of ring formation. [esophagushoncho.com]

  Most theories associate the phenomenon with inborn anomalies of esophageal structure, Gastroesophageal reflux disease, temporary shortenings of the esophagus or pill-related inflammation. [symptoma.com]

  Some lower esophageal rings may be caused by inflammation of the esophagus due to acid reflux or pills that are not completely swallowed (erosive esophagitis). Normally, the lower esophagus has a diameter of about ¾ inch (about 2 centimeters). [merckmanuals.com]

  With inflammation of the lining of the oesophagus (oesophagitis), the lower part of the oesophagus looks red and inflamed. However, if it looks normal it does not rule out acid reflux. [patient.info]

  When it persists for a long time it leads to inflammation. Long term inflammation may cause scarring and increases the likelihood of developing stricture. NSAIDs These drugs should be avoided in patients of GERD. [medlicker.com]

• 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]

• Falling

  It will measure acid reflux activity only for 48 hours and the capsule will usually fall off within 3 to 5 days and is passed. [starpoli.com]

  When backflow of the stomach acid into the esophagus occurs its pH falls. To perform this test a tube is inserted from the mouth to the esophagus, which measures pH and amount of stomach acids in the esophagus over a period of 24 hours. [medlicker.com]

  The diverticulum is seen to protrude posteriorly and the barium tends to fall into the pouch before progressing into the esophagus (Figure 10). Endoscopy adds very little to the evaluation of Zenker's diverticulum. [clevelandclinicmeded.com]

• 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]

• Nausea

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

  Side effects of these drugs are mild and include headaches, diarrhea, nausea, pain abdomen, constipation etc. Sometimes PPIs may be prescribed for a long period of time. [news-medical.net]

  Adverse effects of these drugs when they are used for short term are headache, fatigue, nausea, diarrhea and dizziness. [medlicker.com]

  The exact side effects depend on which type of chemotherapy is used, though fatigue, some nausea, and a decrease in blood counts can result from commonly used chemotherapy agents. [oncolink.org]

• 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]

• Muscle Spasm

  These include muscle spasms, slurred speech, abnormal posture and movements in the body. (1-5) Surgery In severe cases surgery is recommended for GERD. Surgical therapy usually removes the nerves that help produce gastric acid. [news-medical.net]

• Hunger

  Well Photo Credit Illustration by Celia Jacobs Outrunning Hunger Intense exercise may change the way certain neurons influence our appetite and metabolism. [nytimes.com]

• Burning Sensation

  When stomach juices back up into the esophagus, the acid can cause a burning sensation in the chest and throat. [voanews.com]

  Heartburn — A burning sensation in the chest that can extend to the neck, throat, and face, caused by the movement of stomach acid into the esophagus. [medical-dictionary.thefreedictionary.com]

  Symptoms of GORD can include: heartburn (an uncomfortable burning sensation in the chest that often occurs after eating) acid reflux (where stomach acid comes back up into your mouth and causes an unpleasant, sour taste) oesophagitis (a sore, inflamed [nidirect.gov.uk]

  Reflux occurs when the acidic contents of the stomach squeeze or ‘slosh’ back through the sphincter and enter the lower oesophagus, causing symptoms such as heartburn (a burning sensation in the lower chest) or regurgitation. [betterhealth.vic.gov.au]

  This page covers: Symptoms of GORD What to do if you have GORD When to see your GP Treatments for GORD Complications of GORD Symptoms of GORD Symptoms of GORD can include: heartburn (an uncomfortable burning sensation in the chest that often occurs after [nhsinform.scot]

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.