Findings: Small hiatal hernia with Schatzki ring measuring approximately 9-10 mm in diameter which does

not allow passage of barium tablet.

Diagnosis: Small hiatal hernia. Schatzki ring of distal esophagus causing periodic obstruction to solids.

Schatzki Ring

A Schatzki ring is a symptomatic, narrow-caliber ring at the gastroesophageal junction. Microscopically, the
mucosa of the proximal ring is stratified squamous epithelium (esophageal) with columnar epithelium
(gastric) distally. Affected individuals complain of episodic dysphagia for solids. The most frequent offending
agent is an inadequately chewed piece of meat; thus, the condition is often referred to as the "steak house
syndrome." The impacted bolus of food in the distal esophagus causes symptoms ranging from an
uncomfortable "sticking" sensation behind the lower sternum to severe chest pain. Symptoms resolve when
the impacted bolus is passed, regurgitated, or removed. In rare cases, a prolonged bolus obstruction has
caused esophageal perforation. Dysphagia that occurs daily is not likely to be secondary to a Schatzki ring.

The incidence of Schatzki rings has been reported to be up to 14%, but most are asymptomatic. A Schatzki
ring is thought to represent an annular, ringlike structure caused by scarring from reflux esophagitis, but the
pathogenesis is uncertain. Some investigators favor a congenital origin, but symptoms rarely occur prior to
50 years of age. While reflux symptoms are frequently absent in these patients, Schatzki rings have been
observed to progress or transform into true peptic strictures on serial radiographs.

Patients are often treated with behavior modification. These individuals are instructed to eat more slowly and
chew their food more carefully. However, some patients with recurrent dysphagia may require more
aggressive therapy. These patients may require mechanical disruption of the ring by direct endoscopic
rupture, bougienage, electrocautery incision, pneumatic dilatation, or rarely, surgery.

Radiologic Overview of the Diagnosis:

A Schatzki ring appears as a thin (2 to 4 mm in height), weblike constriction at the gastroesophageal

junction which is almost always observed above a hiatal hernia on barium studies. A Schatzki ring has the
same appearance and location as a mucosal ring only it has a smaller caliber and, thus, is clinically
symptomatic. Schatzki rings are visualized on barium studies only if the lumen proximal and distal to the
ring is distended beyond the caliber of the constriction. As a result, the finding may be absent on the double
contrast phase of the examination but may be demonstrated on the single contrast views with the patient in
the prone position. A biphasic esophogram is more sensitive than endoscopy in diagnosing these structures.

While the characteristic appearance of a Schatzki ring is virtually diagnostic, the differential diagnosis also
includes annular peptic stricture, web, or localized esophageal cancer. Annular strictures tend to be more
irregular and asymmetric with a greater height than a Schatzki ring. Esophageal webs that occur in the distal
esophagus are typically located several centimeters or more above the gastroesophageal junction. Thus, the
web can be differentiated from a lower esophageal ring by its more proximal location. A focally infiltrating
esophageal carcinoma can produce a localized constriction, but the presence of asymmetry, irregularity, and
shelflike borders should lead to further evaluation, such as endoscopy, to rule out malignancy.

References:

1. Gore, RM; Levine MS. Textbook of Gastrointestinal Radiology 2nd ed. Philadelphia: W.B.
Saunders, 2000: 487-8.
2. Yamada, T; et al. Textbook of Gastroenterology. New York: J.B. Lippincott, 1991: 566.