Esophageal Ring

Aka: Esophageal Ring, Esophageal Web, Schatzki Ring, Esophageal A Ring, Esophageal B Ring

1. Types: Esophageal Ring
   1. Concentric swelling of tissue (2-5 mm) that protrudes into the esophageal lumen
   2. Typically occurs in the distal esophagus, at the Lower Esophageal Sphincter (LES)
   3. Esophageal A Ring
      1. Esophageal smooth Muscle Contraction at distal esophagus (proximal to the squamocolumnar junction)
   4. Esophageal B Ring
      1. Mucosal swelling in the distal esophagus (at the squamocolumnar junction)
      2. Schatzki Ring (<12.5 mm diameter) is most common Esophageal B Ring
         1. Associated with Hiatal Hernia in most cases, as well as Eosinophilic Esophagitis
2. Types: Esophageal Web
   1. Thin (<2 mm), asymmetric esophageal protrusion into the esophageal lumen, typically in the proximal esophagus
   2. Associated Conditions
      1. Plummer-Vinson Syndrome (Iron Deficiency Anemia, Dysphagia, cervical Esophageal Web)
      2. Zenker's Diverticulum
      3. Bullous Conditions (Epidermolysis Bullosa, Bullous Pemphigoid, Pemphigus Vulgaris)
3. Symptoms
   1. Dysphagia for solids only
4. Diagnosis
   1. Barium swallow (barium esophagram)
   2. Upper Endoscopy (EGD)
5. Differential Diagnosis
   1. See Esophageal Dysphagia
6. Management
   1. Initial approach
      1. Biopsy Esophageal Rings (exclude Eosinophilic Esophagitis)
      2. Dilatation of Esophageal Ring
      3. Proton Pump Inhibitor (e.g. Omeprazole) for 6 weeks after esophageal dilation
   2. Refractory management
      1. Various measures under endoscopy have been used (e.g. intralesional Corticosteroid, incision, laser division)
7. References
   1. Ergon and Kahrilas in Saltzman (2020) Esophageal Rings and Webs, UpToDate, accessed 9/23/2020