Esophageal Webs and Rings Treatment & Management

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

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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