What is Schatzki Ring?
Richard Schatzki was a famous doctor specializing in imaging techniques who first talked about a ring-like formation in patients having difficulty swallowing between 1953 and 1963. This ring was later named after him as “Schatzki ring”. This ring is simply a round layer of lining and the layer just beneath the lining seen at the boundary between the bottom of the throat and the stomach. It looks like a thin, membrane-like structure and doesn’t have any muscle tissue in it. The top of the ring is covered with a type of skin tissue, and the bottom is covered with a tissue type more common in organs like the stomach or intestines, and it’s always found together with a hiatal hernia (a condition where part of the stomach pushes up through the diaphragm).
What Causes Schatzki Ring?
A Schatzki ring is often found along with a condition known as a hiatal hernia. It’s thought that gastroesophageal reflux, which is when stomach acid flows back into the tube connecting your mouth and stomach, might lead to the formation of a Schatzki ring.
Some people believe that your body may form a Schatzki ring to regularly expose itself to acid, as a natural method of preventing a condition called Barrett’s esophagus. It’s a condition where the cells lining your esophagus, the tube that carries food from your mouth to your stomach, change due to regular exposure to stomach acid.
Studies have suggested that people who have a Schatzki ring are less likely to develop Barrett’s esophagus, particularly the long-segment variety.
There is also an association between a condition called eosinophilic esophagitis and the presence of a Schatzki ring. Eosinophilic esophagitis is a chronic immune system disease where eosinophils, a type of white blood cell, build up in the esophagus, leading to damage and inflammation.
Risk Factors and Frequency for Schatzki Ring
Schatzki ring, a condition found during 6% to 14% of routine barium X-ray scans, is known for being the leading cause of occasional difficulty swallowing and food blockages in adults. However, we don’t exactly know how frequently it occurs in the general public, as there have been no large-scale studies on this topic.
Signs and Symptoms of Schatzki Ring
Schatzki rings are often symptomless, although sometimes they can cause a condition known as dysphagia, which makes swallowing difficult and could lead to food getting stuck, often when people don’t chew their food properly. This is known as “Steakhouse syndrome.” Less commonly, people might feel a lump or blockage in their throat, between the areas known as the cricoid and sternal notch. If food is stuck, it can result in painful swallowing.
When symptoms are present, important questions include; finding out the location of discomfort when swallowing, whether it’s usually in the lower chest or upper abdominal area, and whether it’s worse with solids, liquids, or both. Severity of symptoms often depends on how narrow the ring is. The larger the ring (up to 25mm), the greater the likelihood and severity of symptoms, as per the “Schatzki rule”.
Testing for Schatzki Ring
If you are showing symptoms that may indicate the presence of a Schatzki ring, your doctor will likely start by doing a barium esophagram. In simple terms, this is a type of X-ray where you swallow a thick liquid that coats the inside of your throat and stomach. This liquid, known as barium, helps highlight potential issues when the X-ray images are taken.
If your doctor suspects a problem, they may see an area in the lower part of your esophagus (the tube connecting your mouth to your stomach) that’s not stretching as it should. This area may appear as a ring on the X-ray images.
Often, your doctor will ask you to swallow something like a marshmallow or a tablet of barium to see how big the ring is. The next step is typically an endoscopy, which is a test where a long, flexible tube with a camera is used to look at your esophagus.
The endoscopy not only allows your doctor to see the ring but also acts as a form of treatment for those experiencing symptoms. It’s worth mentioning that if the ring is found accidentally and isn’t causing any issues, you won’t need treatment unless it starts causing problems down the line.
However, your doctor may still recommend the endoscopy even if you’re not experiencing symptoms, just to make sure that there’s no other cause for the ring, particularly esophageal cancer. If there’s an unusual looking junction between the stomach and the esophagus, your doctor might collect tissue samples to examine for a condition known as Barrett’s esophagus. Also, the tissue of the ring itself can be sampled as part of the treatment process.
Treatment Options for Schatzki Ring
The aim of treatment is to expand the size of the esophageal ring (a narrow section in the esophagus) so that food or drink can pass through freely. This is usually achieved by breaking the ring, using different methods like stretching it (dilation) or taking small samples of it (biopsies).
The stretching or dilation of the ring is typically done with either a device called a bougie or with a special balloon. A bougie is a slender tool that can be used on its own or with a guiding wire. In some cases, it’s used with a device called a pneumonic balloon dilator. When the bougie is used alone, doctors don’t usually watch the process in real-time, but they can see what’s happening when a guiding wire or balloon dilator is used. An additional method called fluoroscopy, which creates real-time X-ray images, can also be of help during the dilation process.
There’s also evidence that taking biopsies from the ring using large forceps can actually eliminate it, and the good part is, doctors can visualize this procedure through an endoscopy (a type of procedure that allows doctors to view inside the body by inserting a tube with a light and camera). However, biopsies don’t always remove the entire ring, and some experts worry that the leftover tissue may cause the problem to reappear. More research is needed to dig into these concerns.
Patients often take medications that reduce stomach acid, like a proton pump inhibitor (PPI), particularly when the ring has been physically removed or stretched. Studies suggest that using PPIs and dilation together is safe and effective. The impact of using PPIs by themselves was also explored in patients with average ring diameters of around 10 mm. This treatment approach uses a barium-pill esophagram (an X-ray of the esophagus) to follow up with patients, reducing their need to undergo procedures or dilation. Initial studies on this involved only a small group of nine people, and treatment lasts about 10 months on average. Nonetheless, it’s worth considering for patients who have a high risk for procedures or dilations.
What else can Schatzki Ring be?
When investigating for Schatzki ring—a condition that can cause difficulty swallowing—doctors also need to consider other conditions that might be causing the same symptoms. These conditions include:
- Eosinophilic esophagitis (a condition causing inflammation and damage to the esophagus)
- Reflux esophagitis (inflammation of the esophagus due to stomach acid)
- Different types of esophageal strictures
- Compression of the esophagus by surrounding structures
- Problems with esophageal movement
- Cancer
Similarly, if the patient is also experiencing chest pain, doctors need to consider possible esophageal infections, such as yeast infection of the esophagus, or damage to the esophagus from medication, radiation therapy, or rupture—particularly if the symptoms have developed suddenly.
It is also important to note the progression of symptoms. If the difficulty swallowing solid food progresses to also include liquids, this may indicate a worsening obstruction, and there should be a high level of suspicion for cancer. With such a broad range of potential causes, it’s crucial that any new difficulty swallowing is evaluated thoroughly, particularly to rule out more serious conditions like cancer.
What to expect with Schatzki Ring
A Schatzki ring is a non-cancerous narrowing that, when causing symptoms, can be treated effectively. Generally, patients fare well and see an improvement in symptoms after treatment. However, it’s important to note that the ring can reappear, with rates as high as 64% within the first 2 years, and this may call for the procedure to be repeated.
