Esophageal Webs and Rings Workup

Updated: Dec 21, 2019
  • Author: Xaralambos Zervos, DO, MS; Chief Editor: Philip O Katz, MD, FACP, FACG  more...
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Workup

Laboratory Studies

Laboratory testing is not necessary in most patients.

To establish a diagnosis of celiac sprue, iron deficiency anemia, and Paterson-Brown-Kelly syndrome (PVS), the following tests are necessary:

  • CBC count

  • Iron panel

  • Ferritin

  • Antigliadin antibodies

  • Antiendomysial antibodies

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Imaging Studies

Barium swallow

Barium swallow is the diagnostic test of choice and should be the initial test in patients with dysphagia. Barium swallow allows detection of intraluminal obstruction. In addition to detecting esophageal rings and webs, it is useful in excluding other diagnoses, including peptic strictures, pill-induced esophagitis and/or strictures, mucosal tumors, intramural tumors (primarily leiomyomas), and extraesophageal compression. [26] Infections related to candidiasis, cytomegalovirus, herpes simplex virus, and idiopathic ulcers sometimes may be suspected following barium studies.

Barium studies are relatively safe, with low radiation exposure, and relatively inexpensive. Most clinicians believe that the barium swallow is more sensitive than endoscopy in detecting rings and webs. A presbyesophagus (tortuous) or a hypermobile esophagus can prevent detection of a small ring or web by endoscopy. In addition, a barium swallow provides a "roadmap" for the endoscopist.

Reflux of barium provides additional information on the competency of the lower esophageal sphincter and the presence of GER. Finally, the administration of a barium pill at the end of the examination is recommended because the finding of obstruction to a 13-mm pill indicates a high-grade obstruction and the need for esophageal dilation.

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Procedures

Esophagogastroduodenoscopy

Perform upper endoscopy (esophagogastroduodenoscopy) in patients with symptomatic esophageal rings and webs. This procedure is diagnostic and enables therapeutic intervention.

It is probably less sensitive than barium radiography when diagnosing esophageal rings and webs. In fact, the physician occasionally can miss the diagnosis with endoscopy because of the fragility of esophageal webs, hypermotility of the esophagus, the presence of excessive fluid and secretion in the esophagus, presbyesophagus (tortuosity), or very small rings and webs.

In a study of 30 symptomatic patients with a history of a Schatzki ring, Jouhourian et al found evidence that the Bolster technique can improve endoscopic detection of Schatzki rings. The Bolster technique involves applying epigastric abdominal pressure, which may reveal a Schatzki ring that is otherwise obscured within a reduced hiatal hernia. In 26 patients, the Schatzki ring was visible during standard endoscopy, but in 4 patients, it was visible only after the Bolster technique had been applied. [28]

Endoscopy allows biopsy of lesions, such as strictures, polyps, or masses, when any question of malignancy exists.

Routine biopsy of rings and webs is not necessary.

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Histologic Findings

Histologic findings of esophageal rings include normal squamous epithelium, basal cell hyperplasia, hyperkeratosis, proliferative connective tissues, plasma cells, and eosinophilic and lymphocytic infiltration typical of chronic inflammation.

Histologic findings of esophageal webs are usually normal squamous epithelia with occasional chronic inflammatory cells in the subepithelial tissue.

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