Schatzki Ring Treatment & Management

  • Author: Rajeev Vasudeva, MD, FACG; Chief Editor: Julian Katz, MD   more...
 
Updated: Jan 2, 2010
 

Medical Care

Using a large French mercury bougie, polyvinyl bougie, or a balloon, esophageal dilatation is used with the intention of fracturing the ring—not merely stretching it.

  • After initial dilatation, aggressively treat any associated reflux disease. In one prospective, randomized, placebo-controlled study involving 44 consecutive patients, acid suppressive maintenance therapy with omeprazole after bougienage was shown to prevent relapse of the ring as compared to the placebo group. The duration of follow-up was about 60 months, and the mean duration of relapse was 19.9 months.
  • Subsequent dilatations may be needed for recurrence of dysphagia. Determine the need for such dilatations on an individual basis. However, in one study involving only 11 patients, objective measurements with a 12.7-mm barium pill showed that the pill failed to pass the ring in 60% of patients at 1 month and 100% of patients at 1 year. This suggests that recurrence of dysphagia is not a reliable indicator of relapse or persistence of the ring.
  • If dysphagia persists or recurs shortly after dilatation, consider an esophageal manometry study to look for any treatable motility disorder.
  • If the manometry does not reveal any treatable motility disorder, consider repeating an upper endoscopy to assure healing of esophagitis or to confirm persistence of the ring.
  • Rees et al performed a retrospective study of all patients (n = 38; 54 procedures) undergoing transnasal balloon dilation of the esophagus at 2 tertiary care centers to determine the safety of this procedure.[7] The investigators determined that low complication rates are associated with transnasal esophageal balloon dilation in nonsedated or sedated patients, with a 96% well tolerance rate.[7]
  • Based on anecdotal reports, larger pneumatic balloons, such as balloons used for achalasia dilatation, may be considered if the ring persists despite 2 or more bougie dilatations. Fortunately, this measure is rarely required. Use larger balloons with extreme caution because of the increased risk of perforation.
  • Successful endoscopic electrocautery incision using a needle-knife papillotome has been reported and may be considered. A recent randomized, controlled trial compared 52-Fr Maloney dilator versus 4 quadrant biopsy of the ring and found that both modalities were equally effective in relieving dysphagia at 3 months and at 12 months in 26 patients. However, 100% of the biopsy group described the procedure as easy as opposed to 55% of the dilation group.
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Surgical Care

On very rare occasions, one may have to resort to surgical excision if medical therapy fails. Antireflux surgery may also be considered at the same time for concomitant gastroesophageal reflux disease.

In a randomized, prospective trial, Wills et al compared the efficacy of bougie dilation (n = 25) with electrosurgical incision (n = 25) of symptomatic Schatzki rings at 1-year follow-up in the presence of acid suppression with rabeprazole treatment.[8] The investigators found electrosurgical incision of Schatzki rings to be a safe procedure that provided a longer duration of symptom improvement (7.99 mo) relative to bougie dilation (5.86 mo) (P = 0.03). Gastroesophageal reflux disease scores in both groups were significantly improved with the addition of rabeprazole therapy.[8]

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Consultations

On very rare occasions, one may have to resort to surgical excision if medical therapy fails. Antireflux surgery may also be considered at the same time for concomitant gastroesophageal reflux disease.

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Diet

No major dietary restrictions are applicable. The patient may be advised to avoid eating quickly and to chew his or her food well, especially meat and bread; however, whether this advice is truly beneficial is unclear.

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Activity

No restrictions on activity are applicable.

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Contributor Information and Disclosures
Author

Rajeev Vasudeva, MD, FACG  Clinical Professor of Medicine, Consultants in Gastroenterology, University of South Carolina School of Medicine

Rajeev Vasudeva, MD, FACG is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, Columbia Medical Society, South Carolina Gastroenterology Association, and South Carolina Medical Association

Disclosure: Pricara Honoraria Speaking and teaching; UCB Consulting fee Consulting

Specialty Editor Board

Mounzer Al Al Samman, MD  Department of Internal Medicine, Division of Gastroenterology, Assistant Professor, Texas Tech University School of Medicine

Mounzer Al Al Samman, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, and American Gastroenterological Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Noel Williams, MD  Professor Emeritus, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; Professor, Department of Internal Medicine, Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada

Noel Williams, MD is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Alex J Mechaber, MD, FACP  Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine

Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine

Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD  Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania

Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law Medicine and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

References

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Endoscopic appearance of the distal esophagus illustrating a Schatzki ring.
Barium swallow illustrating an indentation at the gastroesophageal junction consistent with a Schatzki ring above a sliding hiatal hernia.
A Schatzki ring dilated by the passage of a single large bougie.
 
 
 
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