History

Most patients with rings and webs of the esophagus have no symptoms. Instead, esophageal webs and rings are detected incidentally on upper GI series and/or upper endoscopy.

The hallmark symptom of esophageal rings and webs is dysphagia.^{[26, 27]}Dysphagia to solid food usually is greater than dysphagia to liquid food. If liquid dysphagia is the predominant symptom, suspect a motility disorder, such as achalasia, nutcracker esophagus, or diffuse esophageal spasm.

Suspect the presence of a symptomatic Schatzki ring in a patient older than 50 years with a chief complaint of intermittent dysphagia to solid food spanning months or years. Other supporting history for Schatzki rings includes heartburn and a hiatal hernia.

The anatomic location of the rings, webs, or narrowing structures causing dysphagia may be inferred from the patient's history. The clinician should ask the patient to locate the area of dysphagia along the sternum.

If the dysphagia is located below the sternum, then the obstruction site is likely in the mid-to-lower esophagus, and an excellent correlation exists between the patient's location and the anatomic obstruction site on barium study or endoscopy.

If the patient's area of dysphagia is located at or above the sternal notch, the obstruction site cannot be determined with any accuracy.

Alarming symptoms that are not consistent with esophageal rings are progressive dysphagia, weight loss, and anemia. These symptoms suggest a mechanical, fixed obstruction, such as a stricture or malignancy, making an early diagnosis mandatory.

Physical Examination

Although most patients with esophageal rings and webs do not have any physical findings, the skin, mucous membrane, and nails may suggest an etiology.

In Paterson-Brown-Kelly syndrome (PVS), physical findings include koilonychia (spoon nails), cheilosis, and glossitis.

Rare skin diseases, such as epidermolysis dystrophica and benign mucous membrane pemphigoid, present with skin bullous lesions.

Acute caustic ingestion of lye or alkaline solution can lead to oropharyngeal injury manifested as ulcerations, exudates, edema, and erythema.

Differential Diagnoses

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Media Gallery

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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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, FAASLD, FRCP(Edin) Professor and Chief, Division of Gastroenterology and Hepatology, Professor of Physiology, Pharmacology, and Neuroscience, Medical Director of Liver Transplantation, Rutgers New Jersey Medical School

Nikolaos T Pyrsopoulos, MD, PhD, MBA, FACP, AGAF, FAASLD, FRCP(Edin) 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 for Gastrointestinal Endoscopy, American Society of Transplantation, International Liver Transplantation Society, Transplantation Society

Disclosure: Received research grant from: GRIFOLS. BAYER, DURECT, INTERCEPT, BEIGENE, BMS.

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

Philip O Katz, MD, FACP, FACG Chairman, Division of Gastroenterology, Albert Einstein Medical Center; Clinical Professor of Medicine, Jefferson Medical College of Thomas Jefferson University

Philip O Katz, MD, FACP, FACG 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: Serve(d) as a speaker or a member of a speakers bureau for: Medtronic<br/>Received income in an amount equal to or greater than $250 from: Torax medical: pfizer consumer, .

Additional Contributors

Waqar A Qureshi, MD, FRCP(UK), FACP, FACG, FASGE Professor of Medicine, Chief of Endoscopy, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

Waqar A Qureshi, MD, FRCP(UK), FACP, FACG, FASGE 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.

Esophageal Webs and Rings Clinical Presentation

History

Physical Examination

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