Clinical and Endoscopic Features of Patients with Esophageal Membranes and Rings

Abstract

Background: Rings and membranes of the esophagus are the most frequently overlooked causes of retrosternal dysphagia. This study evaluates their clinical and endoscopic characteristics and determines differentiating features. Methods: Within a 20-year period, all patients presenting with episodic dysphagia underwent structured interviews as well as endoscopic and radiographic examinations. Patients in whom no morphological lesions were found were also investigated by manometry and/or radionuclide studies. Questions were related to the frequency and duration of dysphagia, bolus obstruction and forced regurgitation. Endoscopy determined the location, type and frequency of luminal narrowing as well as the presence or absence of mucosal inflammation. Radiographic studies were performed as single and double air contrast studies with and without the performance of a Valsalva maneuver. Special attention was given to the number and width of membraneous luminal narrowings, the presence or absence of a hiatal hernia as well as diverticula. Finally we determined the maximum size with which a Maloney bougie could safely be passed through areas of luminal narrowing. Results: A total of 150 patients were found to have Schatzki-Rings (n=113), multiple membranes (n=27), single mebranes (n=6) and muscular webs (n=4). Patients with Schatzki-Rings (SR) were older (58.3 ± 12.9 years=mean ± 1SD) than patients with multiple membranes (MM) (49.8 ± 17.5 years) and had a shorter duration of symptoms (SR: 4.6 ± 5.8 years, MM: 12.6 ± 17.1 years). Hiatal hernias (HH) and erosive esophagitis (EE) were more frequently found in patients with Schatzki-Rings (HH=99%; EE=27%) than in patients with multiple membranes (HH=33%, EE=7%) and heartburn was more frequently reported by patients with Schatzki-Rings (56 vs. 37%). Conversely, intramural diverticula were only found in patients with MM (19%) and never in patients with SR. Finally, esophageal dilation was more difficult to perform in patients with multiple membranes than in patients with Schatzki-Rings. The median size of Bougies passed in patients with SR was 56, while it was 48 in patients with MM. Conclusions: Schatzki-Rings and multiple membranes are the most common causes of episodic dysphagia. Patients with these structural abnormalities differ largely in age, duration of symptoms, associated esophageal lesions and in the ease with which esophageal dilation can be performed.