Schatzki ring
Summary
A Schatzki ring is a thin, mucosal ring of tissue at the squamocolumnar junction of the distal esophagus, usually associated with a small hiatal hernia. It is a common cause of intermittent, nonprogressive solid-food dysphagia (classically with meat, "steakhouse syndrome") when the lumen is narrowed to less than 13 mm.
Detail
DEFINITION/ANATOMY: A Schatzki ring (lower esophageal "B-ring") is a concentric, thin (2-4 mm) web-like ring at the gastroesophageal squamocolumnar junction (Z-line). It is composed of mucosa and submucosa only, with no muscularis propria. The upper surface is squamous epithelium and the lower surface is columnar (gastric) epithelium. It lies at the top of a hiatal hernia. Do not confuse it with the A-ring, which is a muscular ring above the B-ring.
PATHOPHYSIOLOGY: The cause is unclear. Proposed mechanisms are congenital, or acquired from GERD or chronic reflux-related inflammation and fibrosis. It is strongly associated with sliding hiatal hernia. Eosinophilic esophagitis is also associated with it.
CLINICAL PRESENTATION: Many patients are asymptomatic. Symptoms usually appear when the lumen diameter is less than 13 mm (symptoms are typical under ~13 mm and nearly universal under ~12 mm). Dysphagia is intermittent and nonprogressive, and it occurs with SOLIDS only (e.g., bread, meat). Food bolus impaction ("steakhouse syndrome") can occur. Heartburn may coexist from GERD.
DIAGNOSIS: Barium swallow shows a thin, symmetric, circumferential ring in the distal esophagus above a hiatal hernia. Upper endoscopy confirms it and allows treatment. Endoscopy is also used to exclude other causes such as a stricture, malignancy, or eosinophilic esophagitis.
TREATMENT: Treat symptomatic patients with esophageal dilation, either with bougie or balloon dilation, or with a 'rupture' of the ring using a large-bore bougie (e.g., 50-54 Fr). For recurrence, use endoscopic incision or biopsy-based disruption of the ring. Treat GERD with a PPI to reduce recurrence.
HIGH-YIELD COMPARISONS: - Schatzki ring: intermittent solid dysphagia, distal esophagus, nonprogressive. - Peptic stricture: progressive solid then liquid dysphagia, with a long GERD history. - Esophageal carcinoma: progressive dysphagia with weight loss. - Achalasia: dysphagia to both solids and liquids from the start, with a "bird's beak" on barium swallow. - Plummer-Vinson syndrome: upper esophageal web, iron deficiency anemia, glossitis, and increased risk of squamous cell carcinoma (SCC). - Zenker diverticulum: halitosis, regurgitation of undigested food, and a neck mass. - Esophageal rings and webs generally cause solid-food dysphagia.
BOARD PEARL: "Intermittent dysphagia to solids only + hiatal hernia + thin distal esophageal ring on barium swallow = Schatzki ring."
Sources
- First Aid for the USMLE Step 1 (GI: Esophageal pathology)
- Robbins & Cotran Pathologic Basis of Disease (Esophagus)
- Sleisenger and Fordtran's Gastrointestinal and Liver Disease
- UpToDate: Esophageal rings and webs
- Harrison's Principles of Internal Medicine (Disorders of the Esophagus)
Reviewed by Medusa editorial — medical student review. Information here is for study reference only and is not medical advice. Spotted an error? Let us know.