A Schatzki’s ring is a common, non-cancerous band of tissue that forms inside the lower part of the esophagus, the tube that carries food from the mouth to the stomach. Also known as a B-ring, this condition causes a narrowing of the esophageal opening. This narrowing leads to difficulty swallowing, a symptom known medically as dysphagia. It is one of the most frequent structural causes of swallowing difficulty encountered by gastroenterologists.
What is the Physical Structure?
The Schatzki’s ring is a thin, circumferential membrane composed of mucosal and submucosal tissue. It does not contain the muscular layer of the esophagus, which distinguishes it from other types of esophageal rings. The structure is located precisely at the gastroesophageal junction, the border where the lining of the esophagus meets the lining of the stomach.
This anatomical location is also referred to as the squamocolumnar junction, or Z-line, where the pinkish squamous tissue of the esophagus transitions to the reddish columnar tissue of the stomach. The ring acts like a diaphragm, reducing the diameter of the passageway. The severity of swallowing symptoms is directly related to how narrow the ring makes the opening.
Symptoms are highly likely to occur when the ring’s diameter is less than 13 millimeters. Conversely, rings greater than 20 millimeters rarely cause noticeable problems with food passage. The presence of this structure is often associated with a hiatal hernia, where a portion of the stomach protrudes up through the diaphragm.
Symptoms and the Swallowing Experience
The primary complaint for individuals with a symptomatic Schatzki’s ring is intermittent dysphagia, or trouble swallowing. This difficulty is almost always limited to solid foods, while liquids usually pass without issue. Patients frequently describe a sensation that food is “sticking” or “catching” in the lower chest or upper abdominal area.
This sensation is most often triggered by eating hard, dry, or large pieces of food, such as unchewed meat or dry bread. The symptoms are characteristically intermittent and non-progressive, meaning they tend to come and go rather than constantly getting worse. The predictable nature of the symptoms often leads people to slow their eating or chew their food excessively.
A more serious presentation is acute food impaction, sometimes called “steakhouse syndrome,” which occurs when a bolus of food completely lodges in the narrowed ring. This requires immediate medical attention. Other reported symptoms can include chest pain, regurgitation of food, or a feeling of fullness after only a few bites.
How the Ring Develops
The exact process by which a Schatzki’s ring forms is not fully understood, but it is widely considered an acquired condition rather than a congenital one. The most accepted theory links the development of the ring to long-term irritation and inflammation. There is a strong association with chronic gastroesophageal reflux disease (GERD).
GERD involves the frequent backflow of stomach acid and contents into the lower esophagus, which damages the delicate lining. This chronic acid exposure is thought to cause inflammation. As the tissue attempts to heal, it forms a scar-like, thin constriction. The location of the ring at the squamocolumnar junction, the area exposed to reflux, supports this inflammatory response hypothesis.
Some researchers propose that the ring may be a protective mechanism to prevent further acid damage or the development of more serious conditions like Barrett’s esophagus. The ring typically presents in individuals over 40 years old, suggesting an acquired process rather than a birth defect. The presence of a hiatal hernia, which predisposes an individual to GERD, reinforces the connection between reflux and ring formation.
Confirming the Diagnosis and Treatment Options
Confirming the presence of a Schatzki’s ring typically involves two main diagnostic procedures. The first is a Barium Swallow, an X-ray study where the patient drinks a liquid containing barium contrast. The barium coats the esophageal lining, making the ring visible as a sharp, shelf-like indentation.
To diagnose a symptomatic ring, a specialized barium swallow is often performed using a solid food challenge, such as a barium pill, to replicate the swallowing difficulty. The second method is an upper endoscopy, where a thin, flexible tube with a camera is passed down the throat. Endoscopy allows the physician to visualize the ring directly and rule out other causes of narrowing, such as malignancy or esophagitis.
The primary and highly effective treatment for a symptomatic Schatzki’s ring is esophageal dilation. This procedure aims to stretch and fracture the ring to increase the diameter of the esophageal opening. Dilation can be performed using specialized balloons inflated at the site of the ring, or by using tapered plastic or rubber instruments called bougies.
The goal is to dilate the area to a diameter between 16 and 20 millimeters to ensure relief from dysphagia. Because the underlying cause is often chronic GERD, most patients are also prescribed long-term acid-suppressing medication, such as proton pump inhibitors (PPIs). This medication helps manage the reflux, which reduces the risk of the ring reforming and symptoms recurring after dilation.