Narrowing of the distal esophagus may be secondary to Schatzki’s ring. Shatzki’s ring is a mucosal and sub-mucosal shelf located at the squamo-columnar junction and commonly associated with a hiatal hernia. The diagnosis is typically made using a contrast upper gastro-intestinal study. The ring may be easily missed on upper endoscopy. The majority of patients have no symptoms but some patients present with solid food dysphagia, regurgitation, and occasional food impaction. Schatzki’s ring can cause nighttime acid reflux related symptoms. This is due to gastric juice pooling in the esophagus secondary to esophageal obstruction. Pooling occurs at night because gravity drives gastric content into the esophagus especially in the presence of a hiatal hernia. In the setting of a ring, LINX™ device, or tight gastric band, gastric juices tend to linger in the esophagus longer than usual causing GERD related symptoms. The most common nighttime symptom associated with this condition is cough. Gastric juices including acid and possibly bile reach the laryngo-pharyngeal area. Vocal cord irritation and inflammation results in cough and hoarseness. Some patients report waking up from their sleep choking and gasping for air. Others experience food regurgitation and wake up vomiting. I have had experience with several patients with symptomatic Schatzki’s ring. All successfully treated with endoscopic balloon dilation. All patients with Schatzki’s ring that I have so far encountered in my practice, have had an associated sliding hiatal hernia that seems to reduce following dilation.
The pathophysiology of esophageal rings remains poorly understood. Some think that Schatzki’s rings are a congenital malformation while others link ring formation to acid reflux. The fact that most patients with esophageal rings present when they are more than 40 years old points more towards an acquired condition. I think with acid reflux the Z line or squamo-columnar junction tends to move in a cephalad direction. As the Z line retracts faster than the underlying longitudinal esophageal muscle have time to shorten, a mucosal/submucosal ridge develops above the diaphragm. As a result, gastric mucosa herniates above the crus level forming a sliding hiatal hernia that is commonly associated with Schatzki’s ring. Both Schatzki’s ring and a concomitant sliding hiatal hernia may have the same etiology: GERD. In other words, hiatal hernia development in this model is most likely secondary to GERD. GERD after all, is a chronic and progressive multifactorial disease. The accumulation of various insults to the gastro-esophageal junction transforms physiological reflux into GERD, and culminates into the development of a Hiatal hernia. A hiatal hernia further exacerbates GERD and perpetuates the problem of reflux in a vicious circle that is only broken by hiatal hernia repair and Nissen fundoplication surgery.
In the case of Schatzki’s ring, balloon dilation stretches the mucosal and sub-mucosal shelf leading to reduction of the herniated gastric mucosa to its original position below the diaphragmatic crura. Both dysphagia and night time GERD related symptoms resolve. Several studies recommend the use of lifetime proton pump inhibitors like Nexium, Prevacid and Dexilant to prevent Schatzki’s ring recurrence. In my practice, I advise patients to use H2 receptors blockers instead of PPIs to avoid PPI related long-term side effects. In my opinion, ring recurrence can be easily re-dilated and is safer and cheaper than lifelong proton pump inhibitor therapy. The role of Nissen fundoplication and hiatal hernia surgery has not been evaluated in preventing Schatzki’s ring recurrences. However, if GERD were the underlying cause for Schatzki’s rings then Nissen surgery would be the most reliable and durable treatment.