Schatzki Ring Research Articles

Doxycycline-Induced Esophageal Ulceration

Doxycycline-Induced Esophageal Ulceration

The prevalence of intestinal metaplasia in patients with and without peptic strictures

Objectives: Several studies suggest that patients with esophageal peptic strictures have a high prevalence of Barrett's esophagus. However, these studies did not include appropriate control groups, were retrospective in nature, or did not strictly define Barrett's esophagus. Our aim was to compare the prevalence of Barrett's esophagus in patients with and without gastroesophageal reflux diseases strictures in a prospective study. Methods: Seventy-nine patients referred for endoscopy for gastroesophageal reflux disease symptoms were evaluated. We collected demographic information and an esophageal symptom assessment. Biopsy specimens were obtained from peptic strictures, Schatzki rings, or from any areas of columnar-lined esophagus or mucosal injury. Barrett's esophagus was strictly defined as the presence of intestinal metaplasia from tubular esophagus. Results: There were 46 patients without strictures and 28 patients with peptic strictures. Five patients had Schatzki's rings. The prevalence of intestinal metaplasia was 23.9% in patients without strictures, and 25% in patients with peptic strictures ( p = NS). There was no difference in prevalence of short- r long-segment Barrett's esophagus between the groups. Patients with strictures were older than patients without strictures (mean age 58.9 vs 48.6 yr), and more likely to have mucosal injury (50% vs 26.1%). Otherwise, there were no significant differences with regards to gender, race, heartburn duration or frequency. Conclusions: Barrett's esophagus, as defined by the presence of intestinal metaplasia in the tubular esophagus is equally common in patient with and without peptic strictures. There does not appear to be an association between Barrett's esophagus and peptic strictures.

94 Evaluation of standard treatment strategies in a large, multicenter trial: Design issues

Background: Distal esophageal (Schatzki) ring is a frequent cause of dysphagia. Bougienage is generally effective but relapse is common. Outcomes for patients treated by endoscopic incision of distal esophageal rings after symptomatic relapses after bougienage are described. Methods: Eleven patients (2 women, 9 men; median age 61 years; range 24 to 81 years) with recurrent dysphagia after bougienage with large caliber bougies underwent 17 sessions of endoscopic incision of the rings. Follow-up was by standardized interview at a median of 55 months (range, 7 to 84 months) after the initial incision procedure. Results: A median of 3 dilation sessions (range, 1 to >25) were performed prior to incision. All patients noted complete resolution of dysphagia immediately thereafter. Seven required subsequent incision or dilation and 4 did not. The mean dysphagia score was significantly improved from that before incision to that during follow-up. There was a significant increase in the mean duration of improvement in dysphagia after the initial incision compared with that after preincision dilation (respectively, 17 months [range, 2 to 72 months] vs. 5 months [range, 0.5 to 28 months]; p = 0.034). Conclusions: Endoscopic incision of distal esophageal rings that cause recurrent dysphagia after bougienage improves dysphagia and provides a longer dysphagia-free interval compared with repeated bougienage. (Gastrointest Endosc 2002;56:244-8.)

The workup for bariatric surgery does not require a routine upper gastrointestinal series.

Morbid obesity is a serious disease that afflicts over five million Americans, threatening their health with such co-morbidities as diabetes, arthritis, pulmonary failure and stroke. Surgery is the only effective therapy, providing long-term control of weight, diabetes, pulmonary failure, and hypertension for as long as 14 years. Because the operation presents a major expense, this study examined whether X-ray examination of the gut could be omitted safely as a cost-saving measure. The records of 814 consecutive morbidly obese patients who underwent gastric bypass were reviewed to determine: (1) whether these individuals had undergone an upper gastro-intestinal (GI) series, and (2) if these studies influenced therapy or caused cancellation or postponement of surgery. Of the 814 patients, 657 (80.7%) underwent a preoperative GI radiography. Of these examinations, 393 (59.8%) were normal, with the following abnormalities in the remaining 264: hiatal hernia, 164; esophageal reflux, 39; Schatzki's ring, 18; small bowel diverticula, four; renal stones, four; malrotation, three; gall stones, two; pyloric ulcer, one; possible pelvic mass, one; calcified leiomyoma, one; and dysphagial lusoria, one. None of these findings resulted in cancellation or a delay in surgery. The upper GI series can be safely omitted from the routine preoperative evaluation of patients undergoing gastric bypass. At a cost of $741.00 per examination, this change represents significant potential savings. Similar evaluations of other routine preoperative tests may well provide a better basis for the evaluation of these complex patients.

Lower esophageal (Schatzki's) ring: pathogenesis, diagnosis and therapy.

Schatzki's or lower esophageal ring (LER) is one of the most common causes of solid food dysphagia. These rings are associated with hiatal hernias and appear to be produced by an infolding at the junction between the squamous and columnar mucosa. The pathogenesis of LER is not clear, but may be related to gastroesophageal reflux disease (GERD), while GERD and pill injury may worsen the dysphagia associated with LER. LERs are best diagnosed with a combination of history and a carefully performed barium esophogram with solid bolus challenge. Therapy includes instruction in slow and careful mastication. Bougienage is the main form of treatment, but selected patients may require pneumatic dilation, electrosurgical techniques or surgical repair. GERD should be treated if present in these patients.

Localization of an obstructing esophageal lesion. Is the patient accurate?

There are many options as to the accuracy of a patient's subjective localization of an obstructing esophageal lesion. However, there are few studies specifically examining this issue. Over a 35-month period, all patients evaluated by our gastroenterology service undergoing endoscopy for dysphagia were prospectively identified. The patient's subjective localization for the level of obstruction was evaluated by an investigator blinded to the results of prior barium esophagography and recorded on a schematic of the bony skeleton. At the time of endoscopy, the most proximal level of the obstructing lesion was documented. In all, 139 patients with dysphagia and an esophageal stricture were evaluated. Barium esophagograms were performed prior to endoscopy in all but nine patients (6.5%). The most common lesions causing dysphagia were carcinoma (34.5%), gastroesophageal reflux disease (22.3%), and a Schatzki's ring (15.8%). The level of obstruction was localized exactly in 30 patients (21.6%), within +/- 2 cm in 72 (52%), and within +/- 4 cm in 31 additional patients (74%). Eight patients (15%) with a distal esophageal lesion localized the obstruction to the proximal esophagus, whereas only two patients (5%) with a lesion in the proximal esophagus localized the level of obstruction to the distal esophagus. Overall, patients with distal obstructing lesions were more likely to have referral > 6 cm proximally than proximal lesions with referral to the distal esophagus (P = 0.003). There were no significant differences in accuracy based on the cause of dysphagia. In conclusion, a patient's subjective localization of the level of an esophageal stricture is highly accurate. Patients appear to be most accurate in localizing proximal rather than distal lesions.

When is a Schatzki ring clinically significant, and what is the best maneuver to demonstrate it on barium swallow? Does the abnormality progress if it is not treated?

When is a Schatzki ring clinically significant, and what is the best maneuver to demonstrate it on barium swallow? Does the abnormality progress if it is not treated?

Early results with the laparoscopic Hill repair

The open Hill repair is established as a highly effective and durable antireflux procedure. At the present time, we have multi-institutional experience with over 140 laparoscopic Hill repairs. Detailed follow-up on the first 40 patients at our institution is described. All patients had well-documented reflux or esophagitis preoperatively, 7 patients had evidence of peptic stricture or Schatzki's ring, 11 had large hiatal hernia, and 10 weighed more than 200 lb. There were no serious complications and no reoperations. There was 1 death during the follow-up period that was not attributable to the repair. Hospital stay averaged 2.8 days with return to normal activity in 7 to 14 days. Postoperative manometry has been obtained in 24 of the 39 patients available for follow-up (62%) and 24-hour pH studies in 23 of the 39 (59%). Thirty-nine patients were evaluable at a mean follow-up of 10 months and a median follow-up of 8 months (range: 4 to 20 months), with 36 (92%) subjectively rating results as good or excellent. Only one of the three remaining patients has objective evidence of reflux, yielding 97% clinical control of reflux. Mean lower esophageal sphincter pressure (LESP) was raised from 10.7 mm Hg, preoperatively, to 25 mm Hg, postoperatively. Postoperatively, 33 of the 39 patients (85%) are now free of medications referable to the esophagus or upper gastrointestinal tract. This early follow-up experience with the laparoscopic Hill repair leads us to conclude that it is safe, widely applicable, and highly effective as an antireflux operation. Its special features give it certain advantages over the laparoscopic Nissen repair, and we recommend it as the procedure of choice.

Art and science of history taking in the patient with difficulty swallowing.

History taking is the first step in the evaluation of a patient. An analysis of the information obtained provides the basis for the choice and order of diagnostic tests. In addition, it provides the clinician with the necessary information to determine the relevance of "abnormal tests" to the patient's problem. Dysphagia is a reliable symptom that indicates an abnormality in the swallowing mechanism. The history should contain a detailed description of the symptoms associated with dysphagia from the onset. Especially relevant are questions to determine if dysphagia is experienced every day or intermittently, with solid food or liquids or both, as well as presence and timing of associated symptoms such as, choking, coughing and regurgitation, changes in speech, heartburn and chest pain. It is clinically useful to divide swallowing into three phases: oral, pharyngeal and esophageal. Oral dysphagia is usually due to a neurologic disorder, decreased salivary flow or painful oropharyngeal lesions. Pharyngeal dysphagia is most frequently caused by neuromuscular disorders and less frequently by a Zenker's diverticulum, neoplasm or a mucosal web. Esophageal dysphagia is caused by a structural narrowing, such as produced by a peptic stricture, neoplasm or a Schatzki's ring or by a primary motility abnormality, such as achalasia or diffuse esophageal spasm or by motility abnormalities produced by inflammation caused by gastroesophageal reflux, medication-induced esophageal ulceration or infectious esophagitis.

Single dilation of symptomatic Schatzki rings. A prospective evaluation of its effectiveness.

This study investigates the effect of a single dilation on the morphology of the lower esophageal ring and on the clinical course of symptomatic patients. Thirty-three patients were studied prospectively for a mean period of 24.3 +/- 19.2 months. Passage of a large bougie (46-58 F) resulted in a rupture of the ring in each instance and its mean diameter increased from 11.4 +/- 3.6 to 17.2 +/- 4.1 mm. No complications occurred, and all patients were symptom-free at the first follow-up examination four weeks after dilation. However, late symptomatic recurrences were frequent. After one year, the estimated proportion of patients remaining free of symptoms was 68% after two years 35%, and after five years 11%. Repeated treatments were performed with similar ease and effectiveness; again, no complications were encountered. Neither the initial ring size nor the presence or absence of esophagitis determined the likelihood of symptomatic recurrences. It is concluded that single dilations of symptomatic lower esophageal rings are safe, easily performed, and well tolerated. Long-term cure of episodic dysphagia is rare, but recurrences can be successfully treated by repeated dilations.

Ballondilatation von benignen Ösophagusstenosen

Benign stenoses of the oesophagus have been conventionally treated by endoscopic bougienage and were operated on in case of failure. Now that balloon catheters with large balloon diameters are available, interventional radiological dilatation of enteric strictures can be easily performed. In case of eccentric high-grade stenosis with or without blind loop, stenosis is often easier to manage and associated with less risk with an angiographic guide wire and catheter than by endoscopy. 53.3% of the patients were referred to balloon dilatation after failed endoscopic bougienage. The indications for balloon dilatation were anastomotic stenosis (66.2%), peptic stenosis (16.9%), achalasia (7%), pylorospasm (5.6%) and stenosis due to pemphigus vulgaris, acid ingestion and (in one case) a Schatzki ring. The complication rate was low at 1%. The experience collected with 297 dilatations in 71 patients with benign oesophageal stenosis, is reported.

Schatzki’s ring: long-term results following dilation

The purpose of this study is to report long-term results of 61 patients with Schatzki's ring who were dilated for relief of dysphagia. The severity of Schatzki's ring was mild in 28 patients (46%), moderate in 26 (43%), severe in 5 (8%), and indeterminate in 2 (3%). Follow-up information was available in 56 of 61 patients (mean, 75 months). During follow-up, 35 patients (63%) developed recurrent dysphagia and required repeated dilations: 19 patients (34%) had one to two dilations, 9 patients (16%) had three to seven dilations, 6 patients (11%) had more than seven dilations; 1 patient underwent surgery for resection of the Schatzki's ring (2%). The mean (range) dilation-free interval was 50.1 months (11.8 to 100 months) in mild cases, 44.5 months (8.9 to 82 months) in moderate cases, and 28.6 months (9 to 76 months) in severe cases. There was no significant correlation between the severity of Schatzki's ring on initial presentation and the subsequent dilation-free interval. Our data indicate that recurrent dysphagia is common among patients with Schatzki's ring after a successful dilation, and that the severity of Schatzki's ring is not a good prognostic indicator of the need for subsequent dilation.

A New Endoscopic Method for Managing Food Impaction in the Esophagus

Previously described methods for dealing with acute food impaction in the esophagus are not uniformly efficacious, are cumbersome, and often prove dangerous. This paper describes a new technique using an endoscope which is modified such that the endoscope itself becomes a direct-vision suction device. We have successfully used the technique in seven patients with meat bolus impaction in the esophagus. The method proved quick and safe, and no complications occurred. After relieving the impaction an adequate diagnostic examination was done in all patients. In four patients with a predisposing peptic stricture and one with Schatzki's ring, treatment of the lesion was possible during the same endoscopic session.

Cellulose Fiber Diet Pills: A New Cause of Esophageal Obstruction

Cellulose fiber diet pills have recently become a popular form of weight control. In the past 2 months, we have seen two patients in whom ingestion of these pills has resulted in complete distal esophageal obstruction. Further studies revealed that each patient had a previously undiagnosed anatomical abnormality of the distal esophagus; in one case a Schatzki's ring, and in the other a stricture probably secondary to chronic reflux. We conclude that patients with known esophageal narrowing, or with a history of reflux and/or dysphagia, should use cellulose fiber diet pills only with extreme caution.

Gastroesophageal Reflux as a Pathogenic Factor in the Development of Symptomatic Lower Esophageal Rings

Gastroesophageal reflux (GER) has been suggested as a cause of the lower esophageal (Schatzki) ring. We looked for the presence of GER and reflux injury in a series of 20 patients with lower esophageal ring and dysphagia, using a 24-hour esophageal pH monitoring and upper endoscopy with biopsy. Abnormal GER was documented in 13 of the patients (65%), 10 of whom had erosive reflux changes in the distal esophagus. Seven patients (35%) showed no evidence of pathologic GER or reflux esophagitis. All patients also underwent esophageal manometry. Nonspecific esophageal body motor dysfunction may have contributed to dysphagia in five patients, two of whom had no evidence of abnormal GER. We conclude that GER disease is a frequent cause of the gradually progressive ring stricturing and dysphagia seen in patients with lower esophageal ring. Antireflux therapy, as an adjunct to esophageal dilatation, may be appropriate for many symptomatic lower esophageal ring patients.

Analysis of thirty-two patients with Schatzki's ring

Schatzki's ring is a distinct anatomical entity associated with hiatal hernia; however, its significance is unclear. Thirty-two patients with a radiologically demonstrated Schatzki's ring were compared with 32 patients with hiatal hernia and no Schatzki's ring. Schatzki's ring was confirmed on endoscopy in 59 percent of patients. Seventy-five percent of patients with Schatzki's ring presented with dysphagia compared with 41 percent of control patients (p < 0.01). Heartburn and regurgitation were less frequent than in control subjects (38 percent versus 91 percent, p < 0.0001). Schatzki's ring patients were found to have a lower incidence of proven gastroesophageal reflux on 24-hour pH monitoring. Those with proven reflux were found to have a more efficient lower esophageal sphincter than control patients. Sixty-two percent of Schatzki's ring patients without proven reflux had a history of chronic ingestion of drugs known to be damaging to the esophageal mucosa, whereas only 26 percent of patients with reflux had this history. This was found in 16 percent of controls. Sixty-two percent of Schatzki's ring patients without reflux responded to a single dilatation compared with 37 percent of those with reflux. These findings suggest an etiologic relationship between pill lodgement and Schatzki's ring in patients without reflux and indicate that different therapy should be employed in these patients.

Schatzki's Ring: Two Cases with Mid-Esophageal Location

DOI: http://dx.doi.org/10.5915/21-2-13316 The Schatzki's ring is a narrow annular stricture that radiographically appears as a circumferential membrane or web projecting into the lumen at right angle to the long axis of the lower part of the esophagus. This report presents two cases of Schatzki's ring situated almost mid-esophagus, far proximal from the usual location at the squamo-columnar junction. Such rings in a mid-esophageal location have not previously been reported in the literature.

Dysphagia. Diagnostic pitfalls and how to avoid them.

Oropharyngeal and esophageal dysphagia involve different phases of swallowing, have different causes, and can usually be distinguished by a thorough patient history. Initial evaluation of patients with suspected oropharyngeal dysphagia includes patient history, physical and neurologic examination, and careful videofluoroscopic study of pharyngeal dynamics. Initial evaluation of patients with suspected esophageal dysphagia includes patient history and barium swallow with esophagography. Lesions such as Schatzki's ring or peptic stricture may not be detected unless the esophagus is sufficiently distended and the patient is given a bolus challenge.

An Unusually Intractable Schatzki Ring

Most patients with Schatzki's ring have dysphagia that can be relieved by esophageal dilation. We report an unusual case in which dysphagia caused by a Schatzki ring could not be managed conservatively. The obstructing ring was excised through a gastrotomy approached by a left-sided thoracotomy. An antireflux procedure was done after elimination of the ring. Five years later, the patient remained symptom free.

A selection of photographs from the 1987 A/S/G/E Learning Center

1. A 55-year-old male with chronic renal failure had a long history of peptic ulcer disease. Which of the following are true about this unusual pyloric deformity seen at endoscopy? a. More often acquired rather than congenital. b. This is an antral-duodenal fistula. c. Usually requires surgery. d. May contain an ulcer. 2. This 19-year-old bone marrow transplant patient developed odynophagia. At endoscopy extensive ulceration and inflammation were noted. Which of the following are true about this condition? a. This is classic candida esophagitis. b. This condition may occur in all immunosuppressed patients including those with AIDS. c. Endoscopically this is indistinguishable from herpetic esophagitis. d. The causative agent in this condition can frequently be found in other areas of the gastrointestinal tract. 3. A 38-year-old female was endoscoped because of intermittent dysphagia to large pills. This semilunar projection was noted at 20 em from the incisor teeth. Which of the following are true? a. Associated with the Plummer-Vinson syndrome. b. This finding is most compatible with a Schatzki ring. c. May be multiple. d. Initial diagnosis probably best with radiography. 4. A 17-year-old high school football player had an FUO followed in 3 weeks by dysphagia and odynophagia. A barium swallow demonstrated extrinsic compression of the midesophagus, probably by subcarinallymph nodes. Biopsy taken through the small sinus tracts seen at endoscopy revealed granulomatous necrotizing lymphadenitis. This unusual condition is compatible with: a. Crohn's esophagitis b. Occult malignancy c. Cat scratch fever d. Mediastinal lymphoma 5. This laparoscopic view of the liver was seen in a 22-year-old female with abdominal pain, vomiting, and early satiety. Upper gastrointestinal series showed a mass pressing on the stomach. Which of the following are true regarding the lesion seen? a. Usually associated with the use of oral contraceptives. b. May present with intraabdominal hemonhage and shock. c. Should be resected. d. Biopsy is risky. 6. This patient developed deteriorating liver function tests and ascites 10 years following a jejunoileal bypass for obesity. Laparoscopy revealed this appearance of the liver. Expected histology would be: a. Hepatoma b. Adenocarcinoma c. Steatocinhosis d. Multiple adenomas