Diagnosis and Treatment of Schatzki Rings

Diagnosis

Schatzki's ring is an annular constriction at the gastroesophageal mucosal junction, covered proximally by squamous epithelium and distally by gastric mucosa 1
Occurs in 6-14% of barium swallow examinations and is often asymptomatic 1
Schatzki's ring may not be visible during endoscopy unless the gastroesophageal junction is adequately distended by air insufflation 2
Consider excluding eosinophilic esophagitis by obtaining distal, mid and proximal esophageal biopsies in symptomatic patients 3
"Schatzki's rule" states that dysphagia is usual with ring diameters ≤13 mm, rarely occurs if diameter exceeds 20 mm, with a "grey area" between 13-20 mm where symptoms are less consistently observed 2

Common cause of intermittent dysphagia for solids and food bolus obstruction 2
Associated with gastroesophageal reflux disease (GERD) and eosinophilic esophagitis 2

For symptomatic patients, offer a single dilatation session using graded dilatation to a relatively large diameter (16-20 mm) 4, 3
Dilatation therapy is directed toward achieving rupture of the ring, therefore larger calibre dilators may be needed 4
Prescribe PPI therapy (e.g., omeprazole 20 mg twice daily) after dilatation, as this significantly reduces the risk of relapse 5, 3
Some patients with dysphagia due to Schatzki's ring may be relieved by PPI therapy alone without the need for dilatation 2
Electrosurgical incision of the ring is at least as effective as a single large calibre dilatation in relieving dysphagia 4, 3

Long-term PPI therapy (omeprazole 20 mg/day) significantly reduces the risk of relapse compared with placebo at up to 48 months of follow-up 4
Offer PPI therapy rather than H2 receptor antagonists, which are ineffective in reducing the need for repeat dilatation 5

Perforation is a potential risk with any esophageal dilatation procedure, though the risk is lower with Schatzki rings compared to other esophageal strictures 4
Consider performing a water-soluble contrast swallow after dilatation to screen for perforation, though this is not essential 6

Patients with smaller ring diameter (≤13 mm) are more likely to be symptomatic and require intervention 2

Biphasic esophagram is superior to endoscopy for detecting lower esophageal rings, with a 95% detection rate compared to 76% for endoscopy, according to the American College of Radiology 7
Prone single-contrast views with continuous drinking of low-density barium are 2-3 times more likely to detect lower esophageal rings than upright double-contrast views due to better distal esophageal distention, as recommended by the American College of Radiology 7

When encountering esophageal rings, it is essential to exclude eosinophilic esophagitis by obtaining distal, mid, and proximal esophageal biopsies, as this condition can present with circular rings that may mimic Schatzki rings, according to the American Gastroenterological Association 8, 9

Urgent upper endoscopy should be performed to remove the obstructing food bolus in any acute esophageal obstruction. This intervention is essential to relieve obstruction promptly. 10
During the same endoscopic session, graded dilation to a diameter of 16–20 mm should be carried out to rupture the Schatzki ring and reduce the risk of recurrent impaction. A single large‑diameter dilation is preferred over multiple smaller dilations. 11
The primary goal of dilation for Schatzki rings is to achieve ring rupture, which requires larger‑caliber dilators than those used for other esophageal strictures. 12
Esophageal biopsies from distal, mid, and proximal segments should be obtained during the procedure to exclude eosinophilic esophagitis, a condition that can coexist with Schatzki rings and necessitates different therapy. 10

Continue or intensify proton‑pump inhibitor (PPI) therapy after dilation; high‑dose PPI reduces the risk of Schatzki ring relapse for up to 48 months. 11
A typical effective PPI regimen is pantoprazole 40 mg daily (or an equivalent dose of another PPI). 12
PPIs are superior to H₂‑receptor antagonists for preventing recurrence of Schatzki rings and are strongly recommended as the maintenance acid‑suppression strategy. 10
A water‑soluble contrast swallow may be performed after dilation to screen for perforation, although it is not mandatory. 11

Electrosurgical incision of the Schatzki ring is an equally effective alternative to dilation, particularly when dysphagia recurs after initial bougienage. 10
Evidence indicates that electrosurgical incision can provide longer remission periods compared with repeat dilation sessions. 12

Prescribe long‑term PPI maintenance therapy (e.g., omeprazole 20 mg /day or an equivalent pantoprazole dose); this significantly lowers relapse risk compared with placebo. 12
In selected patients, PPI therapy alone may alleviate symptoms without the need for dilation, but acute food‑bolus obstruction still requires urgent endoscopic intervention. 12

In older adults (e.g., ≥85 years), assess procedural tolerance and comorbidities that could increase the risk of endoscopy‑related complications. 10
A single dilation session achieving the target 16–20 mm diameter is preferred over staged, incremental dilations for optimal outcomes. 11