Medical Care
Treatment is aimed at reducing the diameter of the Schatzki ring. [1]
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. Note the following:
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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.
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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.
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If dysphagia persists or recurs shortly after dilatation, consider an esophageal manometry study to look for any treatable motility disorder.
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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.
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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. [14] 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. [14]
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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.
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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.
Consultations
On very rare occasions, surgical excision may be needed if medical therapy fails. Antireflux surgery may also be considered at the same time for concomitant gastroesophageal reflux disease.
Diet and activity
No major dietary restrictions or activity restriction 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.
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.
Surgical approaches have included bougies, balloons, biopsies, and diathermic monopolar incision. [15] Unfortunately, recurrence is common over time.
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. [16] 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. [16]
Successful complete excision of symptomatic Schatzki ring with the use of jumbo cold biopsy forceps has been reported. [17] Gonzalez et al revealed that all 10 patients with dysphagia as a result of a Schatzki ring in their observational study (mean follow-up, 376 days) achieved complete endoscopic obliteration of their Schatzki rings with cold jumbo biopsy forceps. Six of 10 patients had been previously treated with bougienage or balloon dilation, 5 patients were on proton pump inhibitor maintenance therapy, and 1 patient was on H2 blocker maintenance therapy. No serious complications were noted. [17]
Long-Term Monitoring
Recurrence of dysphagia decreases with increasing experience with dilatation.
Repeat esophageal dilatation with a large-bore bougie in patients whose dysphagia recurs.
Monitor patients in follow-up visits (eg, q1-2mo) after initial dilatation and, subsequently, on an as-needed basis.
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Schatzki Ring. Endoscopic appearance of the distal esophagus illustrating a Schatzki ring.
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Schatzki Ring. Barium swallow illustrating an indentation at the gastroesophageal junction consistent with a Schatzki ring above a sliding hiatal hernia.
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Schatzki Ring. A Schatzki ring dilated by the passage of a single large bougie.
