eMedicine Specialties > Gastroenterology > Esophagus

Esophageal Webs and Rings: Differential Diagnoses & Workup

Author: Xaralambos Zervos, DO, MS, Clinical Fellow, Division of Hepatology, Center For Liver Diseases, University of Miami, Jackson Memorial Hospital
Coauthor(s): Nikolaos T Pyrsopoulos, MD, PhD, FACP, Chief of Hepatology, Medical Director of Liver Transplantation, Florida Hospital; Associate Professor of Medicine, University of Central Florida College of Medicine
Contributor Information and Disclosures

Updated: Nov 21, 2008

Differential Diagnoses

Achalasia
Esophageal Leiomyoma
Graft Versus Host Disease
Toxicity, Caustic Ingestions

Other Problems to Be Considered

Peptic stricture
Esophageal tumor
Extrinsic compression
Neuroma
Congenital cartilaginous remnants
Feline esophagus
Aberrant vascular structures
Dysphagia lusoria
Mediastinal irradiation
Pill-induced esophagitis and ulcers
Epidermolysis bullosa dystrophica
Benign mucous membrane pemphigoid

Workup

Laboratory Studies

  • Laboratory testing is not necessary in most patients.
  • To establish a diagnosis of celiac sprue, iron deficiency anemia, and PVS, the following tests are necessary:
    • CBC count
    • Iron panel
    • Ferritin
    • Antigliadin antibodies
    • Antiendomysial antibodies

Imaging Studies

  • Barium swallow
    • This is the diagnostic test of choice and should be the initial test in patients with dysphagia. Barium swallow allows detection of intraluminal obstruction. In addition to detecting esophageal rings and webs, it is useful in excluding other diagnoses, including peptic strictures, pill-induced esophagitis and/or strictures, tumors, intramural tumors (primarily leiomyomas), and extraesophageal compression. Infections related to candidiasis, cytomegalovirus, herpes simplex virus, and idiopathic ulcers sometimes may be suspected following barium studies.
    • Barium studies are relatively safe, with low radiation exposure, and relatively inexpensive. Most clinicians believe that the barium swallow is more sensitive than endoscopy in detecting rings and webs. A presbyesophagus (tortuous) or a hypermobile esophagus can prevent detection of a small ring or web by endoscopy. In addition, a barium swallow provides a "roadmap" for the endoscopist.
    • Reflux of barium provides additional information on the competency of the lower esophageal sphincter and the presence of GER. Finally, the administration of a barium pill at the end of the examination is recommended because the finding of obstruction to a 13-mm pill indicates a high-grade obstruction and the need for esophageal dilation.

Procedures

  • Perform upper endoscopy (esophagogastroduodenoscopy) in patients with symptomatic esophageal rings and webs.
    • This procedure is diagnostic and enables therapeutic intervention.
    • It is probably less sensitive than barium radiography when diagnosing esophageal rings and webs. In fact, the physician occasionally can miss the diagnosis with endoscopy because of the fragility of esophageal webs, hypermotility of the esophagus, the presence of excessive fluid and secretion in the esophagus, presbyesophagus (tortuosity), or very small rings and webs.
    • Endoscopy allows biopsy of lesions, such as strictures, polyps, or masses, when any question of malignancy exists.
    • Routine biopsy of rings and webs is not necessary.

Histologic Findings

Histologic findings of esophageal rings include normal squamous epithelium, basal cell hyperplasia, hyperkeratosis, proliferative connective tissues, plasma cells, and eosinophilic and lymphocytic infiltration typical of chronic inflammation.

Histologic findings of esophageal webs are usually normal squamous epithelia with occasional chronic inflammatory cells in the subepithelial tissue.

More on Esophageal Webs and Rings

Overview: Esophageal Webs and Rings
Differential Diagnoses & Workup: Esophageal Webs and Rings
Treatment & Medication: Esophageal Webs and Rings
Follow-up: Esophageal Webs and Rings
Multimedia: Esophageal Webs and Rings
References
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Further Reading

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Keywords

esophageal webs and rings, esophageal webs, esophageal rings, rings and webs, contractile ring, contraction ring, benign annular stricture, lower esophageal muscular ring, multiple esophageal webs, multiple esophageal rings, MER, congenital esophageal stenosis, corrugated esophagus, feline esophagus, ringed esophagus, Schatzki ring, steak-house syndrome, steakhouse syndrome

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Contributor Information and Disclosures

Author

Xaralambos Zervos, DO, MS, Clinical Fellow, Division of Hepatology, Center For Liver Diseases, University of Miami, Jackson Memorial Hospital
Xaralambos Zervos, DO, MS is a member of the following medical societies: American College of Physicians, American Medical Association, and American Osteopathic Association
Disclosure: Nothing to disclose.

Coauthor(s)

Nikolaos T Pyrsopoulos, MD, PhD, FACP, Chief of Hepatology, Medical Director of Liver Transplantation, Florida Hospital; Associate Professor of Medicine, University of Central Florida College of Medicine
Nikolaos T Pyrsopoulos, MD, PhD, FACP is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Liver Foundation, American Medical Association, American Society of Gastrointestinal Endoscopy, American Society of Transplantation, International Liver Transplantation Society, and Transplantation Society
Disclosure: Gilead Sciences Honoraria Speaking and teaching; Schering-Plough Honoraria Speaking and teaching; Roche Honoraria Speaking and teaching

Medical Editor

Waqar A Qureshi, MD, Associate Professor of Medicine, Chief of Endoscopy, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine and Veterans Affairs Medical Center
Waqar A Qureshi, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Simmy Bank, MD, Chair, Professor, Department of Internal Medicine, Division of Gastroenterology, Long Island Jewish Hospital, Albert Einstein College of Medicine
Disclosure: Nothing to disclose.

CME Editor

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.

 
 
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