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Esophageal Webs and Rings Treatment & Management

  • Author: Xaralambos Zervos, DO, MS; Chief Editor: Julian Katz, MD  more...
 
Updated: Jul 24, 2015
 

Approach Considerations

Esophageal rings and webs usually are managed in the outpatient setting. Patients with recurrent symptoms from esophageal rings and webs require repeat esophageal dilation. Repeat esophageal dilation is safe and can relieve symptoms in the long term.

Histamine type 2 (H2)-receptor antagonists, including cimetidine, famotidine, and ranitidine, may be used for mild-to-moderate GERD symptoms.

For severe GERD symptoms, proton pump inhibitors (eg, omeprazole, lansoprazole, rabeprazole, pantoprazole) are recommended.

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Medical Care

Lower esophageal rings and webs

Most esophageal rings are found incidentally, are asymptomatic, and do not require treatment.

Instruct patients with mild symptoms to modify their diet and eating habits by eating soft food, cutting solid food into smaller pieces, and eating slowly.

Before patients take oral medications, warn patients of the hazard of pills lodging in their esophagus; hence, they should cut large sized pills into smaller pieces prior to ingestion when possible. In addition, instruct patients to drink at least 8 ounces of liquid and to avoid laying supine for at least 30 minutes after taking their oral medications. These precautionary measures may prevent pill-induced esophagitis even in patients without esophageal disorders.

If these conservative measures are not adequate in preventing dysphagia, esophageal dilation with mechanical bougie is indicated.

Patients with eosinophilic esophagitis and evidence of proximal strictures and multiple mucosal rings may benefit from fluticasone propionate 220 µg/puff, twice daily without spacer.

Esophageal dilation

Two types of mechanical bougies are used for esophageal dilation, Savary dilator and Maloney (mercury filled) dilator. Both types of bougies are graded in millimeters (mm) and French (1F = 3 mm). Both types of dilators are equally effective and safe. Perform an initial endoscopy prior to esophageal dilation to confirm the diagnosis when using Maloney dilators. With Savary dilators, an endoscopy is a part of each dilation procedure.

The goal of using mechanical bougies is to disrupt the rings rather than stretching them. In most cases, passage of one large bougie is adequate to disrupt the ring. Despite a lack of conclusive evidence, passing a single large bougie is believed to be more effective than serial progressive dilation of esophageal rings.

Fluoroscopic visualization rarely is needed for either procedure, but it is recommended if the lumen distal ring cannot be visualized.

A persistent ring after esophageal dilation as shown in postdilation barium study does not predict failure of therapy. In fact, in a prospective study by Eckardt et al, 33 consecutive patients with symptomatic esophageal rings experienced relief of their dysphagia after passage of a single Maloney bougie (46-58F), regardless of ring rupture.[25] However, repeat dilation is safe and effective.

Unlike the lower esophageal rings, patients with multiple esophageal rings follow a set of different therapeutic rules for esophageal dilation. This recommendation is based on the author's cumulative experience with this rare condition. The esophageal lumen in patients with multiple esophageal rings is typically much narrower than in patients with lower esophageal rings. Medical therapy alone is usually unsuccessful. The treatment of choice is mechanical dilation. Unlike lower esophageal rings, multiple esophageal rings are tighter, and dilation should be performed very slowly using the smallest size dilator that encounters moderate resistance on initial passage into the esophageal lumen. Initially, only one dilator should be used, with serial dilations reserved for later sessions. Starting with a 20-30F dilator is not uncommon. Transient chest pain from mucosal tear is common after dilation in this population.

Patients with multiple rings may be presenting with eosinophilic esophagitis. Dilation in these patients should be performed with care, as deep mucosal tears and esophageal perforations may occur.

For esophageal rings refractory to esophageal dilation, therapeutic success using neodymium:yttrium-aluminum-garnet (Nd:YAG) laser therapy has been reported. In a study of 14 patients by Hubert et al, Nd:YAG laser incision of lower esophageal rings provided good symptomatic relief.[26]

Like distal esophageal rings, most esophageal webs are asymptomatic and do not require treatment. Mild symptoms often can be treated with diet modification and lifestyle changes (see Patient Education). If these conservative measures are unsuccessful, esophageal dilation with mechanical bougie is the next step in treatment. Esophageal dilation with endoscope, bougie, and an esophageal balloon is effective in disrupting esophageal webs, resulting in long-term relief.

Like esophageal rings, postdilation barium study may reveal a persistent esophageal web despite symptom relief. Successful treatment of an esophageal web using Nd:YAG laser has been reported, but this treatment rarely is required. In patients with associated disorders, such as iron deficiency, inflammatory diseases, or chronic graft versus host disease, treating the underlying disorders is warranted.

Newer technology in endoscopic dilation has been studied by Jones et al in a group of 26 patients who presented with dysphagia, as follows[27] :

  • The InScope Optical Dilator that allows actual visualization during dilation was used on these patients. Seventeen patients had evidence of peptic stricture, and 9 with Schatzki ring were dilated. Eighteen of these 26 patients reported either significant or complete resolution of the dysphagia at week 3 postdilation.
  • The dilations were performed by 2 operators that related the experience similar to the use of bougies with respect to intubation and tactile response. The significant benefit reported was increased visualization during dilation.
  • The authors concluded that larger scale trials should be undertaken to validate the theory that direct visualization has an added benefit in esophageal dilation. Patients with eosinophilic esophagitis may benefit the most by this method as dilation of multiple rings may be aborted if excessive tear is seen.

Using the Clinical Outcomes Research Initiative (CORI) database, based in Portland, Oregon, Olson et al reviewed 7287 patients with strictures and 4993 patients with rings, all with distal lesions, who were compared to 124,120 control subjects, to evaluate the demographic characteristics of patients with symptomatic strictures and rings, to describe the indications and types of therapeutic dilations, and to determine the rate of repeat dilation within 1 year of the initial dilation.[28] Note the following:

  • Strictures showed predominance in males, and rings showed predominance for women, both affecting elderly white patients more than other demographic groups.
  • Rings were more often dilated with bougies, and strictures were more likely to require repeated dilation. Repeat dilation for strictures and rings at 1 year was 13% and 4%, respectively. The mean interval length between repeat dilations was 82 days for strictures and 184 days for rings. Dysphagia and reflux symptoms represent the most common indications for esophagogastroduodenoscopy (EGD) in patients who ultimately receive dilation.
  • The study limitation, as acknowledged by the authors, was that there was no way to track those patients who switched gastrointestinal specialists and were now being followed by providers who do not participate in the CORI database.

Consultations

Refer patients with symptomatic esophageal rings or webs to a gastroenterologist.

Diet and activity

Patients with mild symptoms from esophageal rings or webs should modify their diet and eating habits.

Soft food, such as pasta, vegetables, and carbohydrates, is less likely than meat to become lodged in the esophagus.

Advise patients to eat slowly, chew thoroughly, and cut large chunks of food into smaller pieces.

Modification of physical activities is not necessary.

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Surgical Care

Esophageal rings and webs rarely need surgical therapy.

Endoscopic sphincterotomy

Endoscopic electrocautery incision using a papillotome catheter was reported to be successful in alleviating symptoms associated with refractory lower esophageal rings in 2 studies involving 7 and 17 patients.

In the first study, 7 patients were observed for as long as 36 months with only 1 patient requiring a second treatment at 6 months and 1 patient developing chest pain after treatment. The patient continued to have persistent dysphagia from the ring but no new symptoms, unlike the patient who developed new-onset chest pain, which is likely a complication from the treatment.

In the second study, 17 patients had a mean follow-up care of 14 months, with 3 patients requiring a second treatment and 1 patient having bleeding.

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Contributor Information and Disclosures
Author

Xaralambos Zervos, DO, MS Assistant Program Director, Hepatology Fellowship, Florida Hospital Transplant Center; Assistant Professor, Department of Medicine, University of Central Florida College of Medicine

Xaralambos Zervos, DO, MS 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 Medical Association, American Osteopathic Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Coauthor(s)

Nikolaos T Pyrsopoulos, MD, PhD, MBA, FACP, AGAF Chief of Gastroenterology and Hepatology, Medical Director of Liver Transplantation, Division of Gastroenterology and Hepatology, Rutgers New Jersey Medical School

Nikolaos T Pyrsopoulos, MD, PhD, MBA, FACP, AGAF 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 Society for Gastrointestinal Endoscopy, American Society of Transplantation, American Liver Foundation, International Liver Transplantation Society, Transplantation Society, American Gastroenterological Association, American Medical Association

Disclosure: Received consulting fee from Gilead Sciences for consulting.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD Clinical Professor of Medicine, Drexel University College of Medicine

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 & Ethics, American Trauma Society, Association of American Medical Colleges, Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Additional Contributors

Waqar A Qureshi, MD Professor of Medicine, Chief of Endoscopy, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

Waqar A Qureshi, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Acknowledgements

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.

References
  1. Hirano I, Gilliam J, Goyal RK. Clinical and manometric features of the lower esophageal muscular ring. Am J Gastroenterol. 2000 Jan. 95(1):43-9. [Medline].

  2. Muller M, Gockel I, Hedwig P, et al. Is the Schatzki ring a unique esophageal entity?. World J Gastroenterol. 2011 Jun 21. 17(23):2838-43. [Medline]. [Full Text].

  3. Winters GR 3rd, Maydonovitch CL, Wong RK. Schatzki's rings do not protect against acid reflux and may decrease esophageal acid clearance. Dig Dis Sci. 2003 Feb. 48(2):299-302. [Medline].

  4. 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.

  5. Ingelfinger FJ, Kramer P. Dysphagia produced by a contractile ring in the lower esophagus. Gastroenterology. 1953 Mar. 23(3):419-30. [Medline].

  6. Schatzki R, Gary JE. Dysphagia due to a diaphragm-like localized narrowing in the lower esophagus (lower esophageal ring). Am J Roentgenol Radium Ther Nucl Med. 1953 Dec. 70(6):911-22. [Medline].

  7. Norton RA, King GD. "Steakhouse syndrome": the symptomatic lower esophageal ring. Lahey Clin Found Bull. 1963 Jul-Sep. 13:55-9. [Medline].

  8. Miller DW Jr, Wichern WA Jr. Lower esophageal rings, webs, and annular strictures. Ann Thorac Surg. 1968 Oct. 6(4):401-12. [Medline].

  9. Fonkalsrud EW. Esophageal stenosis due to tracheobronchial remnants. Am J Surg. 1972 Jul. 124(1):101-3. [Medline].

  10. Anderson LS, Shackelford GD, Mancilla-Jimenez R, et al. Cartilaginous esophageal ring: a cause of esophageal stenosis in infants and children. Radiology. 1973 Sep. 108(3):665-6. [Medline].

  11. Okamura H, Tsutsumi S, Inaki S, et al. Esophageal web in Plummer-Vinson syndrome. Laryngoscope. 1988 Sep. 98(9):994-8. [Medline].

  12. Chisholm M, Ardran GM, Callender ST, et al. Iron deficiency and autoimmunity in post-cricoid webs. Q J Med. 1971 Jul. 40(159):421-33. [Medline].

  13. Elwood PC, Jacobs A, Pitman RG, Entwistle CC. Epidemiology of the Paterson-Kelly syndrome. Lancet. 1964 Oct 03. 2(7362):716-20. [Medline].

  14. Wong PW, Shaffer R, Kadakia SC. Esophageal manometry, 24-hour pH monitoring and clinical characteristics in 12 adults with multiple esophageal. Gastroenterology. 2000 APr. 118(4 Pt 1):A491.

  15. Chen MY, Ott DJ, Donati DL, et al. Correlation of lower esophageal mucosal ring and lower esophageal sphincter pressure. Dig Dis Sci. 1994 Apr. 39(4):766-9. [Medline].

  16. Marshall JB, Kretschmar JM, Diaz-Arias AA. Gastroesophageal reflux as a pathogenic factor in the development of symptomatic lower esophageal rings. Arch Intern Med. 1990 Aug. 150(8):1669-72. [Medline].

  17. Ott DJ, Ledbetter MS, Chen MY, et al. Correlation of lower esophageal mucosal ring and 24-h pH monitoring of the esophagus. Am J Gastroenterol. 1996 Jan. 91(1):61-4. [Medline].

  18. Sgouros SN, Vlachogiannakos J, Karamanolis G, et al. Long-term acid suppressive therapy may prevent the relapse of lower esophageal (Schatzki's) rings: a prospective, randomized, placebo-controlled study. Am J Gastroenterol. 2005 Sep. 100(9):1929-34. [Medline].

  19. Smith PM, Kerr GD, Cockel R, et al. A comparison of omeprazole and ranitidine in the prevention of recurrence of benign esophageal stricture. Restore Investigator Group. Gastroenterology. 1994 Nov. 107(5):1312-8. [Medline].

  20. Jacobs A, Kilpatrick GS. The Paterson-Kelly syndrome. Br Med J. 1964 Jul 11. 2(5401):79-82. [Medline].

  21. Bredenkamp JK, Castro DJ, Mickel RA. Importance of iron repletion in the management of Plummer-Vinson syndrome. Ann Otol Rhinol Laryngol. 1990 Jan. 99(1):51-4. [Medline].

  22. Dickey W, McConnell B. Celiac disease presenting as the Paterson-Brown Kelly (Plummer-Vinson) syndrome. Am J Gastroenterol. 1999 Feb. 94(2):527-9. [Medline].

  23. Siafakas CG, Ryan CK, Brown MR. Multiple esophageal rings: an association with eosinophilic esophagitis: case report and review of the literature. Am J Gastroenterol. 2000 Jun. 95(6):1572-5. [Medline].

  24. Remedios M, Campbell C, Jones DM, et al. Eosinophilic esophagitis in adults: clinical, endoscopic, histologic findings, and response to treatment with fluticasone propionate. Gastrointest Endosc. 2006 Jan. 63(1):3-12. [Medline].

  25. Eckardt VF, Kanzler G, Willems D. Single dilation of symptomatic Schatzki rings. A prospective evaluation of its effectiveness. Dig Dis Sci. 1992 Apr. 37(4):577-82. [Medline].

  26. Hubert G, Patrice T, Foultier MT, et al. [Dysphagia and Schatzki ring: treatment using the Nd-YAG laser in 14 patients]. Gastroenterol Clin Biol. 1990. 14(2):186-7. [Medline].

  27. Jones MP, Bratten JR, McClave SA. The Optical Dilator: a clear, over-the-scope bougie with sequential dilating segments. Gastrointest Endosc. 2006 May. 63(6):840-5. [Medline].

  28. Olson JS, Lieberman DA, Sonnenberg A. Practice patterns in the management of patients with esophageal strictures and rings. Gastrointest Endosc. 2007 Oct. 66(4):670-5; quiz 767, 770. [Medline].

  29. Arora AS, Perrault J, Smyrk TC. Topical corticosteroid treatment of dysphagia due to eosinophilic esophagitis in adults. Mayo Clin Proc. 2003 Jul. 78(7):830-5. [Medline].

  30. Buckley K, Buonomo C, Husain K, Nurko S. Schatzki ring in children and young adults: clinical and radiologic findings. Pediatr Radiol. 1998 Nov. 28(11):884-6. [Medline].

  31. Burdick JS, Venu RP, Hogan WJ. Cutting the defiant lower esophageal ring. Gastrointest Endosc. 1993 Sep-Oct. 39(5):616-9. [Medline].

  32. Chen YM, Gelfand DW, Ott DJ, et al. Natural progression of the lower esophageal mucosal ring. Gastrointest Radiol. 1987. 12(2):93-8. [Medline].

  33. Chisholm M. The association between webs, iron and post-cricoid carcinoma. Postgrad Med J. 1974 Apr. 50(582):215-9. [Medline].

  34. Chisholm M, Ardran GM, Callender ST, et al. A follow-up study of patients with post-cricoid webs. Q J Med. 1971 Jul. 40(159):409-20. [Medline].

  35. DeVault KR. Lower esophageal (Schatzki's) ring: pathogenesis, diagnosis and therapy. Dig Dis. 1996 Sep-Oct. 14 (5):323-9. [Medline].

  36. Ekberg O, Nylander G. Webs and web-like formations in the pharynx and cervical esophagus. Diagn Imaging. 1983. 52(1):10-8. [Medline].

  37. Feldman M, Scharschmidt BF, Zorab R, eds. Caustic injury to the upper gastrointestinal tract. Sleisenger and Fordtran's Gastrointestinal and Liver Disease: Pathophysiology/Diagnosis/Management. 6th ed. 1998. 335-6.

  38. Godino J, Wong PW. A triad of troubling findings. Plummer-Vinson syndrome. Postgrad Med. 2000 Aug. 108(2):109-10. [Medline].

  39. Guelrud M, Villasmil L, Mendez R. Late results in patients with Schatzki ring treated by endoscopic electrosurgical incision of the ring. Gastrointest Endosc. 1987 Apr. 33(2):96-8. [Medline].

  40. Hoover WB. The syndrome of anemia, glossitis, and dysphagia. N Engl J Med. 1935. 213:394-8.

  41. Krevsky B, Pusateri JP Jr. Laser lysis of an esophageal web. Gastrointest Endosc. 1989 Sep-Oct. 35(5):451-3. [Medline].

  42. Losurdo J, Bruninga K, Dobozi B, et al. Idiopathic eosinophilic esophagitis: A new cause of "feline" esophagus (abstract). Gastroenterology. 1999. 116:A239.

  43. Marks RD, Richter JE, Rizzo J, et al. Omeprazole versus H2-receptor antagonists in treating patients with peptic stricture and esophagitis. Gastroenterology. 1994 Apr. 106(4):907-15. [Medline].

  44. Jones RF. The Patterson-Brown Kelly syndrome. Its relationship to iron deficiency and postcricoid carcinoma. J Laryngol Otol. 1961. 75:529-561. [Medline].

  45. Morrow JB, Vargo JJ, Goldblum JR, Richter JE. The ringed esophagus: histological features of GERD. Am J Gastroenterol. 2001 Apr. 96(4):984-9. [Medline].

  46. Nihoul-Fekete C, De Backer A, Lortat-Jacob S, Pellerin D. Congenital esophageal stenosis. A review of 20 cases. Pediatr Surg Int. 1987. 2(2):86-92.

  47. Nosher JL, Campbel WL, Seaman WB. The clinical significance of cervical esophageal and hypopharyngeal webs. Radiology. 1975 Oct. 117(1):45-7. [Medline].

  48. Olson JS, Lieberman DA, Sonnenberg A. Practice patterns in the management of patients with esophageal strictures and rings. Gastrointest Endosc. 2007 Oct. 66(4):670-5; quiz 767, 770. [Medline].

  49. Remedios M, Campbell C, Jones DM, et al. Eosinophilic esophagitis in adults: clinical, endoscopic, histologic findings, and response to treatment with fluticasone propionate. Gastrointest Endosc. 2006 Jan. 63(1):3-12. [Medline].

  50. Schatzki R, Gary JE. The lower esophageal ring. Am J Roentgenol Radium Ther Nucl Med. 1956 Feb. 75(2):246-61. [Medline].

  51. Seamen WB. Pharyngeal and upper esophageal dysphagia. JAMA. 1976 Jun 14. 235(24):2643-6. [Medline].

  52. Shamma'a MH, Benedict EB. Esophageal webs; a report of 58 cases & an attempt at classification. N Engl J Med. 1958 Aug. 259(8):378-84. [Medline].

  53. Straumann A, Rossi L, Simon HU, et al. Fragility of the esophageal mucosa: a pathognomonic endoscopic sign of primary eosinophilic esophagitis?. Gastrointest Endosc. 2003 Mar. 57(3):407-12. [Medline].

  54. Tobin RW. Esophageal rings, webs, and diverticula. J Clin Gastroenterol. 1998 Dec. 27(4):285-95. [Medline].

  55. Waldmann HK, Turnbull A. Esophageal webs. Am J Roentgenol. 1957. 78:567-573. [Medline].

  56. Webb WA, McDaniel L, Jones L. Endoscopic evaluation of dysphagia in two hundred and ninety-three patients with benign disease. Surg Gynecol Obstet. 1984 Feb. 158(2):152-6. [Medline].

  57. Wright VM, Walker WA, Durie PR. Pediatric Gastrointestinal Disease. Philadelphia, Pa: Decker; 1991. 369-70.

  58. Yamada T, ed. The esophagus, anatomy, physiology and disease. The Textbook of Gastroenterology. Baltimore, Md: Lippincott Williams & Wilkins; 1991. 540.

 
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Diagram of A, B (Schatzki), and C rings in the distal esophagus. The B ring marks the proximal border of a hiatal hernia. V=vestibule and HH=hiatal hernia.
Schatzki ring with a distal hiatal hernia.
Schatzki ring on barium swallow.
Meat (chicken) impaction within a Schatzki ring.
Multiple esophageal rings found throughout the entire esophagus.
An upper esophageal web (arrow) in a patient with Plummer-Vinson syndrome.
Upper gastrointestinal series showing upper esophageal webs (small arrows) in a patient with Plummer-Vinson syndrome. Incidental finding of a small Zenker diverticulum (large arrow).
Postcricoid esophageal web and an inlet patch (arrows outlining the border).
 
 
 
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