IMAGE OF THE WEEK

WEEK 24

SCHATZKI RING (SCHATZKI GARY RING OR 'B' RING)

Schatzki ring or also known as ‘B’ ring is a diaphragm-like fixed stricture located at the gastro-oesophageal junction (GOJ) and is widely believed to be associated with chronic acid injury from gastro-oesophageal reflux disease. The stricture is made of mucosa hyperplasia.

Schatzki or Schatzki Gary ring is named after American-German scientist Richard Schatzki and his colleague JE Gary who first report the condition in 1953.

On endoscopy, Schatzki ring appears a thin diaphragm stricture at the GOJ and is often associated with a hiatus hernia (Figure 1). The proximal side of the mucosa is covered by slate coloured squamous mucosa whereas the distal side is covered by salmon coloured columnar mucosa. Often, there is no endoscopic oesophagitis. Interestingly, the incidence of Barrett’s oesophagus, a premalignant condition (especially in those with dysplasia) is lower in those with Schatzki ring. This is presumably due to the protective effects of the ring that prevent significant acid reflux into the oesophagus proximal to the ring.

The underlying pathogenesis is not exactly known. However, it is widely accepted that it is due to acid injury. 63% of patients with Schatki ring have abnormal 24 hours pH monitoring.

Schtazki ring is actually quite common and is reported in 6 to 14% of barium contrast study. However, most are incidental finding and only 0.5% has symptoms attributable to the ring. The most common reported is non progressive intermittent dysphagia to solid, some referred to as the ‘Steakhouse syndrome’. Dysphagia only occurs when the oesophageal lumen is less than 13mm and often asymptomatic if larger than 20 mm. Most patients do not complain of gastro-oesophageal reflux symptoms.

It is common in those age 40 years and above. Interestingly, there is no gender or racial predilections.

The treatment for symptomatic Schatzki ring is dilatation which may need to be repeated and prolonged acid suppression.

Notes on other types of oesophageal rings/webs:

The ‘A’ ring is a narrowing secondary to hypertrophied muscle typically found 2-3 cm above the GOJ. Most are asymptomatic.

The oesophageal web or ring usually is usually found in the proximal oesophagus and is synonymous with Plummer Vinson syndrome. Some has referred it to as ‘AA’ ring.

Images prepared by Dr Chong Vui Heng, Consultant Gastroenterologist & Hepatologist, Department of Gastroenterology & Hepatology, RIPAS Hospital, Brunei Darussalam.

All images are copyrighted and property of RIPAS Hospital.