Oesophageal rings/webs

Definitions:

• Web: <2mm thick eccentric membrane that protrudes into oesophageal lumen. Most commonly anterior in cervical oesophagus
• Ring: concentric diaphragm of tissue, typically distal oesophagus

Presentation:

• Thin structures that partially occlude the oesophageal lumen
• Usually asymptomatic
• Can have intermittent dysphagia to solids
• Unknown pathogenesis/prevalence

Anatomy:

Non-pathological indentation can be caused at three locations

• • 'A' ring - just proximal to squamocolumnar junction
    • Normal smooth muscle contraction
    • Size of hiatus hernia measured from diaphragmatic impression to A ring - should be <3cm to be normal
  • 'B' ring - at the squamocolumnar junction
  • Diaphragmatic impression (sometimes called 'C' ring - distal oesophagus/proximal stomach

Pathological indentation

• • Schatzki ring - most common type of ring - narrow mucosal B ring <12.5mm in diameter, generally just proximal to a hiatus hernia
    • Concentric, non-malignant, fibrous thickening in submucosal layer
    • Possibly caused by reflux disease but not pathognomic
    • Almost always associated with a hiatal hernia
    • Also a/w eosinophilic oesophagitis
    • Do not need to be biopsied in the absence of mucosal abnormalities

• Webs
  • Plummer-Vinson syndrome - cervical oesophageal web, iron deficiency anaemia, dysphagia. Typically white women in their 30-60s. Risk factor for SCC.
    • Other clinical features: glossitis, angular cheilitis, koilonychia, splenomegaly, enlarged thyroid

Workup:

• Generally diagnosed on Barium swallow
  • Should have a subsequent upper endoscopy for biopsies to exclude eosinophilic oesophagitis and malignancy
• Gastroscopy
  • Web
    • Circumferential/eccentric narrowing of normal mucosa, generally cervical
  • Ring
    • Concentric narrowing, typically distal oesophagus

Management:

• Asymptomatic - no treatment
• If symptomatic - can have dilation (bougie or balloon) followed by PPI
  • Repeated dilatations are often necessary
  • Schatzki rings are best treated with passage of a single large bougie dilator to rupture the ring
  • Webs also respond well to bougie dilation
• If refractory to this - treat with repeat dilations and PPI, consider steroids/incision
• Few other surgical options