eMedicine Specialties > Gastroenterology > Esophagus

Esophageal Webs and Rings: Treatment & Medication

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

Treatment

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.24 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.25
    • 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.26
      • 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 of direct visualization as an added benefit to 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.27
      • 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.

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. Whether the single patient that required a second treatment developed any symptoms is not clear. 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 mean follow-up care of 14 months, with 3 patients requiring a second treatment and 1 patient having bleeding.

Consultations

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

Diet

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.

Activity

Modification of physical activities is not necessary.

Medication

Therapy targets underlying causes of esophageal rings and webs.

Antireflux therapy is indicated if GERD is associated with esophageal rings or webs. Evidence of GERD includes classic symptoms of pyrosis (heartburn worsens after meals or when lying flat) and extraesophageal symptoms (chronic cough, globus sensation, hoarseness, asthmalike symptoms refractory to bronchospasm therapy). Other evidence for GERD includes esophagitis, peptic strictures, and abnormal acid exposure on esophageal pH monitoring.

Iron therapy is indicated for PVS and iron deficiency anemia.

Proton pump inhibitors

Decreases gastric acid secretion by inhibiting the parietal cell H+/K+ ATP pump.


Omeprazole (Prilosec)

Indicated for short-term treatment (4-8 wk) of GERD.

Adult

20 mg/d PO for 4-8 wk

Pediatric

Not established

May decrease effects of itraconazole and ketoconazole; may increase toxicity of warfarin, digoxin, and phenytoin

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Bioavailability may increase in persons who are elderly; associated with headache, diarrhea, and abdominal pain


Lansoprazole (Prevacid)

Inhibits gastric acid secretion. Used for as many as 4 wk to treat and relieve symptoms of active duodenal ulcers.

Adult

30 mg/d PO for 4-8 wk

Pediatric

Not established

May decrease effects of ketoconazole and itraconazole; may increase theophylline clearance

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Bioavailability may increase in persons who are elderly; associated with headache, diarrhea, and abdominal pain

Minerals

Used to treat iron deficiency anemia.


Ferrous sulfate (Feosol, Feratab, Fer-Iron, Mol-Iron)

A nutritionally essential inorganic substance indicated for treatment of iron deficiency anemia.

Adult

325 mg PO qd/tid

Pediatric

<15 kg: 5 mg/kg/d PO
15-30 kg: One half of adult dose
>30 kg: Administer as in adults

Absorption is enhanced by ascorbic acid; interferes with tetracycline absorption; food and antacids impair absorption

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

GI upset; iron toxicity is observed with ingestion of large amount and can be fatal, especially in children; adjust dose if constipation occurs (stool softeners may be beneficial)

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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