Inferior
Esophageal Ring Formation
The inferior esophageal ring, eponymously known as a Schatzki ring, is
a round and regular mucosal web circumferentially indenting the esophageal
lumen that forms at the squamocolumnar junction at the gastroesophageal
junction. It is a commonly acquired ring typically occurring in middle age and
associated with gastroesophageal reflux, though this has never been well
proven. More recent data have further demonstrated similar rings in patients
with eosinophilic esophagitis, suggesting that the ring may be a response to a
chronic inflammatory process other than reflux at the gastroesophageal
junction.
Further diagnostic difficulties stem from differentiating this ring
from an annular peptic stricture. Using strict definitions, the ring contains
only mucosa, whereas a stricture is an abnormality of deeper esophageal wall
layers with fibrotic changes. The visual appearance may be helpful because a
ring seen by radiographic or endoscopic means is a relatively thin membranous
structure, in contrast to a stricture, which appears thicker. The
cardinal symptoms of an inferior esophageal ring are intermittent dysphagia
and/or food impaction with solid food. It is the most common cause of
solidfood dysphagia in adults. Because symptoms result from the mechanical
process in which a bolus of food that is too large tries to pass through a
lumen that is too small, foods that cause symptoms are typically chunky hard
solids, such as meats, bread, and raw vegetables. Earlier data suggested that
the diameter of the ring dictates the chance of a food bolus sticking, but
other factors, such as types of food, attention to bolus mastication, and use
of fluids with the meal, further affect the likelihood of food bolus
obstruction. Treatment of an inferior esophageal ring is mechanical disruption,
which may be accomplished through biopsy or balloon or Savary dilation. For
more recalcitrant rings, endoscopic incision may also be used. Recurrence is
common, and pharmacologic antireflux therapy is often used to prevent ring
formation, though no data are available to support this recommendation.
