Multiple Esophageal Rings Research Articles

Clinical, endoscopic, and histologic characteristics of lymphocytic esophagitis: a systematic review.

Lymphocytic esophagitis (LyE) is a novel, yet poorly described, clinicopathologic entity. The aim of this systematic review was to characterize the demographic, clinical, endoscopic, and histologic features of LyE in observational studies of adult and pediatric patients. We searched the Embase, MEDLINE, and SCOPUS databases for relevant studies in 2018. Two authors reviewed and extracted data from studies that met the inclusion and exclusion criteria. We identified 20 studies for analysis of demographic, clinical, and endoscopic features of LyE. The mean age ranged from 9 to 67years. When pooled, there were 231 (52.7%) patients with LyE that were female. The most common presenting symptom was dysphagia reported in 191 (48.8%) patients. On endoscopy, most patients with LyE tended to have abnormal findings (69.0%), which included erosive esophagitis, multiple esophageal rings, linear furrows, and narrow-caliber esophagus. In the 31 studies used to assess the histologic definition, the cut-off number of intraepithelial lymphocytes (IELs) was reported in 16 (51.6%) studies, peripapillary IEL specification in 18 (58.1%) studies, and presence of spongiosis in 6 (19.4%) studies. We identified a spectrum of demographic, clinical, and endoscopic findings characteristic of patients with LyE. A consensus on the diagnostic criteria of LyE is required.

Swiss Cheese Esophagus: A Case of Esophageal Intramural Pseudodiverticulosis

Diverticula can be seen throughout the gastrointestinal tract including the Esophagus. Esophageal Intramural Pseudodiverticulosis (EIPD) is a rare condition characterized by the presence of multiple pinhead-sized outpouchings of the esophageal wall, giving the esophagus the appearance of Swiss cheese on endoscopy. We present a case of EIPD in a patient with eosinophilic esophagitis (EoE). To our knowledge, this is the first case describing EIP with concomitant EoE. A 72 year old Caucasian male presents to a gastroenterology clinic for evaluation of dysphagia. He underwent endoscopy as part of his evaluation, which revealed multiple esophageal diverticula as well as distal esophageal strictures. The patient underwent successful esophageal stricture dilation and was advised to follow up for a repeat endoscopy. He followed with another gastroenterologist for the next 3 years where he was diagnosed with Eosinophilic Esophagitis (EoE). He was treated with oral budesonide slurry but continued to have recurrent dysphagia. He presented with a complaint of “macaroni stuck” in his throat. The food bolus passed spontaneously and on endoscopy he had multiple esophageal rings as well as pseudodiverticulosis. The patient underwent Savary dilation, followed by multiple repeat stricture dilatation sessions in the following months. He subsequently had complete resolution of his dysphagia, while on budesonide, and had a satisfactory endoscopic appearance on the most recent endoscopy, except for the pseudodiverticulosis. EIPD was first described in 1960 by the British Institute of Radiology. To date a little over 200 cases of EIP have been described in the literature. Unlike colonic diverticula, the exact mechanism by which EIPD forms is unclear. It seems, however, to be affected by chronic inflammation whereby the structural integrity of the esophageal lining, especially at the excretory ducts of the submucosal glands, is compromised leading to the formation of diverticula. This rare entity represents a unique challenge, especially in the presence of other concomitant conditions. In our patient, both EoE and EIPD can lead to dysphagia and stricture formation. This raises an interesting question: Are the strictures a result of EIPD or EoE or both? Also, if EIPD is associated with chronic inflammatory states then why is it not more commonly seen with conditions such as reflux esophagitis?Figure 1

Esophageal trachealization: A feature of eosinophilic esophagitis

Eosinophilic esophagitis (EE) is an inflammatory condition characterized by intense eosinophilic infiltration of the esophagus. EE is frequently misdiagnosed as gastroesophageal reflux disease. Here, we present a child with EE and a characteristic endoscopic finding, “ringed esophagus”. An 11-year-old Saudi boy presented with dysphagia for 1 year. He had experienced an intermittent sensation of solid food sticking in his chest, which was relieved by drinking liquids. A barium swallow excluded anatomical causes of dysphagia, but revealed multiple-ringed esophagus. Endoscopy showed a furrowing and trachealizing appearance of the entire esophagus. Hisologically, extensive eosinophilic infiltration was a feature in biopsies obtained from the esophagus. The child responded well to a 2-month course of inhaled fluticasone. Symptoms recurred 3 months after discontinuation of therapy, which necessitated resumption of inhaled fluticasone. The endoscopic appearance of multiple esophageal rings should raise suspicion of EE and be confirmed by esophageal biopsies.

Gender Differences in Patients Presenting with Dysphagia

Background: Dysphagia is a common cause of referral for upper endoscopy. Gender differences within such a cohort have not been previously described in the literature. We hypothesized that the etiology of dysphagia would differ by gender. Aim: To determine if gender differences exist among the etiology of dysphagia in patients presenting for upper endoscopy. Methods: A prospective analysis was performed on all patients undergoing upper endoscopy for the indication of dysphagia between 1/1/2006 and 6/1/2007 at the University Hospital. All patients completed dysphagia symptom assessment along with validated gastroesophageal reflux questionnaires. Endoscopic findings and demographics were also recorded. Results: A total of 190 patients were enrolled (92 males, 98 females). Males and females were similar in age of presentation (49.7 ± 15.0 vs. 52.8, ± 16.3), duration of symptoms (8.2 ± 9.0 vs. 6.0 ± 8.7), and severity of dysphagia scores (median 1.9 ± 1.4 vs. 2.1 ± 1.5). A significant difference in the distribution of endoscopic findings exist between males and females (p < 0.004). Multiple esophageal rings are more prevalent in males than females (28.6% vs. 13.9%, p < 0.02). Schatzki's Rings (SR) are described more in females than males (20.8% vs. 6.1%, p < 0.01) [see table]. A history of esophageal food impaction (EFI) occurred more frequently in males (30.4% vs. 17.3%, p < 0.04). A high prevalence of multiple esophageal rings was found in both genders who described prior EFI (males 55.6%, females 46.7%). Prior food impaction increased the likelihood of finding multiple esophageal rings in females (OR 7.7, p < 0.03), but not in males (OR 1.8, p = NS). Conclusion: The endoscopic findings and history of esophageal food impaction in patients presenting with dysphagia differ significantly by gender. History of esophageal food impaction greatly increases the likelihood of finding multiple esophageal rings in females. Suspicion of multiple esophageal rings should be high not only in men, but also in women who present with EFI and dysphagia.

Intermittent Dysphagia for Solids Associated with a Multiringed Esophagus: Clinical Features and Response to Dilatation

The entity of the multiringed esophagus, generally presenting in adults as intermittent dysphagia for solids, is relatively uncommon and its pathogenesis is unknown. The goal of this study was to describe the demographic, clinical, and endoscopic features of patients presenting with this condition, their response to esophageal dilatation, and the relationship of multiple esophageal rings to eosinophilic esophagitis. Between 1989 and June 2004, 32 patients at this adult hospital fulfilled the following inclusion criteria: (1) intermittent dysphagia for solids, (2) multiple esophageal rings at endoscopy, and (3) esophageal dilatation(s) performed. Response to esophageal dilatation was measured by need for subsequent dilatations. Seventy-five percent of the patients were male. Median age at onset of dysphagia was 21 years and at presentation 36.5 years. All had multiple rings in the proximal or midesophagus on endoscopy and had undergone a total of 73 esophageal dilatations with no esophageal perforations. Median maximal dilator size was 15 mm; however, 16% developed significant esophageal mucosal tears even with 11-mm dilators. Sixty-six percent required repeat dilatation, with the median time interval before recurrence being 8 months. Eosinophilic esophagitis (mucosal eosinophil count > 20/HPF) was present in 50% of this cohort. From this study we conclude that a multiringed esophagus causing intermittent dysphagia occurs predominantly in young males, responds well to dilatation, but repeated dilatations are often necessary. Dilatation can lead to extensive mucosal tears and should be performed with caution. Eosinophilic esophagitis is commonly but not invariably associated with this entity. Frequent relapse of dysphagia highlights the need for effective pharmacotherapy.

Eosinophilic Esophagitis and Esophageal Perforation

Eosinophilic esophagitis (EE) has been described in both adults and children. We report a patient with esophageal perforation due to EE. A 69 year old female was admitted for sudden onset of odynophagia and dysphagia after eating meat, followed by retching and hematemesis. Surprisingly, EGD revealed a blood filled esophagus and a 4–5 cm full thickness upper esophageal defect without active bleeding. Additional findings of concentric rings and diffuse distal esophageal narrowing were compatible with eosinophilic esophagitis based on classic endoscopic appearance. The impacted food bolus was successfully removed at the index endoscopic examination. Following the bolus extraction, gastrograffin esophogram showed extravasation of contrast. CT scan confirmed the presence of mediastinal air and pleural effusions. Non-operative management was initiated with antibiotics and total pareneral nutrition. Repeat esophagram at 5 days was normal and a soft diet was gradually introduced and tolerated. EE is an uncommon disorder in which the esophagus is infiltrated with eosinophils. It is associated with food allergies, asthma, allergic rhinitis, atopic dermatitis, urticaria, GERD, multiple esophageal rings, and eosinophilic gastroenteritis. It is seen more commonly in children and young adult males. Esophageal dysmotility and a characteristic furrowed esophagus are frequently observed. Multiple rings and strictures account for dysphagia and potential for food impaction. EE is diagnosed by direct visualization and supported by esophageal biopsy. There is no definitive treatment, but symptomatic treatment, allergy testing, food elimination, and steroids are management options. Dilation of long concentric ringed strictures should be undertaken with care due to the potential for esophageal rents and increased risk of perforation. Acid suppression alone is rarely successful. Treatment with swallowed (inhalation) fluticasone or leukotriene antagonists are additional useful therapeutic options. EE may present with dysphagia or food impaction. Esophageal perforation may occur in the setting of esophageal obstruction. Non operative management may be successful when esophageal perforation results as a complication of EE.

Multiple esophageal rings: histology, EUS, and manometric findings

Pseudotumor cerebri syndrome (PTCS) is defined by the presence of elevated intracranial pressure in the setting of normal brain parenchyma and cerebrospinal fluid. PTCS can occur in the pediatric and adult populations and, if untreated, may lead to permanent visual loss. In this review, discussion will focus on PTCS in the pediatric population and will outline its distinct epidemiology and key elements of diagnosis, evaluation and management. Finally, although the precise mechanisms are unclear, the underlying pathophysiology will be considered.

Multiple esophageal rings: an association with eosinophilic esophagitis: Case report and review of the literature

Esophagitis may present endoscopically with erythema, edema, loss of vascular pattern, friability, and ulceration of the esophageal mucosa. Left untreated, chronic esophagitis may result in stricture formation. The presence of multiple concentric rings involving the entire esophagus has been cited as a chronic form of esophagitis. We present a case of an 8-yr-old boy with multiple concentric esophageal rings and histological evidence of eosinophilic esophagitis, who failed medical antireflux treatment and responded to an elimination diet.

Esophageal manometry, 24-hours pH monitoring, and clinical characteristics in 12 adults with multiple esophageal rings

Esophageal manometry, 24-hours pH monitoring, and clinical characteristics in 12 adults with multiple esophageal rings

Multiple esophageal rings: An atypical manifestation of gastroesophageal reflux disease?

Multiple esophageal rings: An atypical manifestation of gastroesophageal reflux disease?

Dysphagia due to Multiple Esophageal Rings

A 27-year-old Saudi man with dysphagia due to multiple esophageal rings is reported and the literature reviewed. Dysphagia due to multiple esophageal rings is very rare. Only 15 cases have been reported. The patient is usually male and has had dysphagia for many years when presenting. The cause of the rings is unknown. Theories to explain dysphagia are that the rings are either congenital or an unusual manifestation of gastroesophageal reflux.

Multiple esophageal rings

Multiple esophageal rings