Relatively common, lower oesophageal rings are found in ~10% of barium swallows.
Most commonly it presents as intermittent dysphagia, especially to solid food. A history of food impaction is also very common. Dysphagia is more common in patients with an associated motility disorder.
The pathogenesis of the Schatzki ring is unclear with conflicting hypotheses that include redundant pleats of mucosa, congenital abnormalities and modified peptic strictures. Interestingly, there is a reduced incidence of Barrett oesophagus in patients with a Schatzki ring.
Depending on its luminal diameter, an oesophageal B-ring may be symptomatic or asymptomatic 4:
- <13 mm: almost always symptomatic
- 13-20 mm: sometimes symptomatic
- >20 mm: rarely symptomatic
When it is symptomatic, it is termed a "Schatzki ring".
Schatzki rings are located at the gastro-oesophageal junction, illustrated by the fact that there is squamous epithelium above and columnar epithelial below the ring. They should not be confused with
- A-rings, which are found a few centimetres proximal to the B-ring
- oesophageal webs, which are lined on both sides by oesophageal mucosa 6-8
More than half of patients will have an associated oesophageal condition such as 2:
Fluoroscopy: barium swallow
Single-contrast solid barium swallows (especially in the RAO prone position) are more sensitive than endoscopy in detecting Schatzki rings 3. On barium swallow the following features may be seen 1:
- full-column barium swallow will reveal a circumferential narrowing at the gastro-oesophageal junction, often a few centimeters above the diaphragmatic hiatus
- thin smooth ring, 2-4 mm
- double contrast studies are less sensitive
- performing a Valsalva manoeuvre may improve sensitivity
- barium-tablet or barium-coated marshmallow may also improve sensitivity
History and etymology
It is named after Richard Schatzki (1901-92), American physician (born in Germany) 1.
On fluoroscopy consider
- oesophageal A-ring
- oesophageal web
- oesophageal stricture: longer, with tapered ends
- distal oesophageal carcinoma: usually irregular in appearance
- oesophageal dysmotility
- oesophageal tumours
- benign oesophageal neoplasms
- malignant oesophageal neoplasms
- gastro-oesophageal reflux disease
- oesophageal stricture
- 1. Kanne JP, Rohrmann CA, Lichtenstein JE. Eponyms in radiology of the digestive tract: historical perspectives and imaging appearances. Part I. Pharynx, esophagus, stomach, and intestine. Radiographics. 26 (1): 129-42. doi:10.1148/rg.261055084 - Pubmed citation
- 2. Müller M, Gockel I, Hedwig P et-al. Is the Schatzki ring a unique esophageal entity?. World J. Gastroenterol. 2011;17 (23): 2838-43. Free text at pubmed - Pubmed citation
- 3. Pezzullo JC, Lewicki AM. Schatzki ring, statistically reexamined. Radiology. 2003;228 (3): 609-13. doi:10.1148/radiol.2283021162 - Pubmed citation
- 4. Gore RM, Levine MS. Textbook of Gastrointestinal Radiology. Saunders. (2008) ISBN:1416023321. Read it at Google Books - Find it at Amazon
- 5. Liu, Julia J., and Peter J. Kahrilas. "Pharyngeal and esophageal diverticula, rings, and webs." GI Motility online (2006).
- 6. Smith MS. Diagnosis and management of esophageal rings and webs. Gastroenterol Hepatol (N Y). 2011;6 (11): 701-4. Free text at pubmed - Pubmed citation
- 7. Nurko S, Teitelbaum JE, Husain K et-al. Association of Schatzki ring with eosinophilic esophagitis in children. J. Pediatr. Gastroenterol. Nutr. 2004;38 (4): 436-41. Pubmed citation
- 8. Patel B, Han E, Swan K. Richard Schatzki: a familiar ring. AJR Am J Roentgenol. 2013;201 (5): W678-82. doi:10.2214/AJR.13.10748 - Pubmed citation