Schatzki’s Rings are the most common of the types of esophageal rings. Their prevalence varies with the population being studied and the diagnostic technique deployed. They are rarely documented and described from reports emanating from this environment. This article seeks to document one such case and briefly discuss aspects of its clinical significance and management.Keywords: Schatzki’s Ring, Nigeria, Gastroscop

A O, Oluyemi

O, Oyedeji

English

AJOL - African Journals Online

     © Sudan JMS Vol. 10, No.2. June 2015                    73 Vtáx exÑÉÜà Schatzki’s Ring in a Nigerian at Gastroscopy Oluyemi AO1* and Oyedeji O2 Abstract Schatzki’s Rings are the most common of the types of esophageal rings. Their prevalence varies with the population being studied and the diagnostic technique deployed. They are rarely documented and described from reports emanating from this environment. This article seeks to document one such case and briefly discuss aspects of its clinical significance and management. Keywords: Schatzki’s Ring, Nigeria, Gastroscopy  y definition, an esophageal ring is a concentric, smooth, thin (3-5 mm) extension of normal esophageal tissue consisting of 3 anatomic layers of mucosa, submucosa, and muscle. They are most commonly encountered in the lower third of the esophagus but can be present anywhere along the length of the structure.  The most frequently encountered of these esophageal rings is the Schatzki’s ring (SR). SR is defined as a thin, symmetric, concentric, mucosal structure projecting into the esophageal lumen and located at the esophagogastric junction1. SR consists of only mucosa and submucosa2. SRs are not an uncommon finding as western literature quotes a prevalence rate between 0.2 to 14% depending on the diagnostic technique deployed1 and this quoted figure can go as high as 15% to 26% among those being investigated for dysphagia with endoscopy3. However, SRs are a rare finding endoscopic series from our locality. The presence of SR does not result in significant complaints in most patients as most are thought to be asymptomatic incidental findings. But SR can also result in esophageal symptoms-particularly  as  it _____________________________________________ 1.  ReMay Consultancy & Medical Services,Opebi, Ikeja, Lagos State. Nigeria.  2. College of Medicine, University of Lagos, Lagos State. Nigeria. *Correspondence to: Oluyemi, AO.  E-mail: remioluyemi@yahoo.com is thought to be the commonest cause of long-term episodic dysphagia in adults3,4.  This article seeks to document one such SR finding from a Nigerian who presented for gastroscopy and present a short discussion of pertinent clinical aspects and management. CASE REPORT: A 64 year old man was referred for a routine screening endoscopy at our Nigeria-based endoscopy clinic. The man had no symptoms or signs referable to the gastrointestinal system. Notably he denied any history of difficulty or pain on swallowing, troublesome heartburn, regurgitation, nor dyspepsia. The procedure was uneventful and the only interesting finding was a circumferential, mucosal projection in the lower third of the esophagus at the squamo-columnar junction. The ring did not result in any significant compromise of the caliber of the esophageal lumen and it anatomically marked the proximal margin of a hiatus hernia. The surrounding mucosa was free of erythema or erosions (Figure 1). DISCUSSION: Schatzki’s ring (SR) is a thin circumferential ring located at the squamocolumnar junction in the lower esophagus and comprising of mucosa and submucosa, it usually marks the proximal end of a hiatus hernia2,5. BOluyem © SudanDespiteclinical Gary,4 unclearAt leastfor this:1.The rthat ftransireason2.The ri3.Somestrictugastro4.Yet conse11. Figure esophagbeyond These exclusivthat bothem12. to be esophagthe sthereforetiologySRs ardetectedwesternyears oli & Oyedej JMS Vol.  being chaentity sincthe patho.   4 hypothe ing is a pleorms whenently or pes6. ng is conge also consre occurrinesophagealothers opquence of p(1):  Schatus with ait. hypotheses e as thereth supporSRs have associateeal abnormymptomatie sugge9,12.  e rare in  after the literature8,d. i                10, No.2. Juracterized e 1953 by genesis of ses have bat of redun the esopharmanently nital in oriider it a g as a con reflux diseine that ill-inducedzki's Ring  hiatus hmay not  are cogent and refualso consisd with alities pac individsts a mchildren a age of 13 our index       Schatzkne 2015      as a distinSchatzki anSR is steen proposdant mucogus shortefor unknowgin1,7. short peptsequence ase2,8,9. SR is  esophagitiat the lowernia visibbe mutualt argumente each tently showmany othrticularly uals. Thultifactorind most a40 years  case was 6i’s Ring in              74ct d ill ed sa ns n ic of a s9- er le ly ts of n er in is al re in 4 HareplaesricoMaswfoby00wthdynosoprinLbomTwthreridipaZotthcoprrePoofsuinTgaiswprre a Nigerianistologicalle usually ithelium yered by ophageal wng, but thvered solelost SRs ar was our pell documer dysphagia a large s0 dysphagas the fourtis symptsphagia ofn-progresslids(dysphesent). Tgestion9,14.arge-bore ugienage (ainstay of his procedith either ough balloported (whng—not mlation shotients witenker diveher conditie risk mplicationoperly, boulieving symst dilation  acid supprperior to cidence of his case stroscopy  rarely noterite up seeactitioners ality of th at Gastroscy, the supecovered band its incolumnareb may me web cay by squame consideratient. Bunted to be  in adults, cale surveyia patientsh commoneom3.It ap SR is inteive dagia to liquypically,  endoscop15 mm/45 therapy forure is freqSavary or on dilatioich work erely stretculd not h eosinoprticulum, bons that sigof perfors15. Wgienage is ptoms.  or bougienessants hasplacebo relapses16. report repfinding fromd in publisks to sensiin our envis and furtopy – Caserior surfacey squamoferior sur epitheliuimic an eson be defous epitheled asymptot these lesia prominenthis was co of more t which shst associatpears thrmittent, eysphagia ids is usuduring ic dilatioFr or large symptomauently peMaloney n has alsby fracturhing it). Hbe performhilic esopullous disenificantly ation or hen pequite succeage, aggres been showat reduciresents a  Nigeria whed literatutize the endironment aher enlight report of SRs us cell face is m The phageal ined as ium2. matic14 ons are t reason nfirmed han 30, owed it ion with at the pisodic, to ally not hurried n or r) is the tic SRs. rformed dilators, o been ing the owever, ed in hagitis, ase, or increase other rformed ssful at sive use n to be ng the unique here it re. The oscopy s to the en with Oluyemi & Oyedeji                       Schatzki’s Ring in a Nigerian at Gastroscopy – Case report © Sudan JMS Vol. 10, No.2. June 2015                    75 discussions on pertinent clinical aspects and management.   REFERENCES: 1. Goyal RK, Glancy JJ, Spiro HM. Lower esophageal ring. N Engl J Med 1970;282:1298-305. 2. Ott DJ, Ledbetter MS, Chen MY, Koufman JA, Gelfand DW.Correlation of lower esophageal mucosal ring and 24-h pH monitoring of the esophagus. Am J Gastroenterol 1996;91:61-4. 3. Krishnamurthy C, Hilden K, Peterson KA, Mattek N, Adler DG, Fang JC. Endoscopic findings in patients presenting with dysphagia: analysis of a national endoscopy database. Dysphagia  2012;27(1):101-5. 4. Schatzki R, Gary JE. Dysphagia due to a diaphragm-like localized narrowing in the lower esophagus (lower esophageal ring). Am J Roentgenol Radium TherNucl Med 1953;70:911-22. 5. Wilkins EW. The lower esophageal ring. how unique. Ann Thoracic Surgery 1984;37:101-2. 6.  Steinnon AW. An anatomic basis for lower esophageal contraction ring: plication theory and its application. Am J Radiol1963;90:811. 7. Longstreth GF. Familial lower esophageal rings.N Engl JMed 1982;307:443. 8. Marshall JB, Kretschmar JM, Diaz-Arias AA. Gastroesophageal reflux as a pathogenic factor in the development of symptomatic lower esophageal rings. Arch Intern Med1990;150:1669-72. 9. Jamieson J, Hinder RA, DeMeester TR. Analysis of thirty-two patients with Schatzki's ring. Am J Surg Dec 1989;158(6):563-6. 10. BonavinaL, DeMeester TR, McChesney L, Schwizer W, Albertucci M, Bailey RT. Drug-induced esophageal strictures. Ann Surg 1987;206:178-83. 11. Bailey RT Jr, Bonavina L, McChesney L, Spires KJ, Muilenburg MI, McGill JE, DeMeester TR. Factors influencing the transit of a gelatin capsule in the esophagus. Drug Intell Clin Pharm 1987;21:282-5. 12. Müller M, Gockel I, Hedwig P, Eckardt AJ, Kuhr K, König J, Eckardt VF. Is the schatzki ring a unique esophageal entity? World J Gastroenterol 2011;17(23):2838-43.  13. Towbin AJ, Diniz LO. Schatzki ring in pediatric and young adult patients. Pediatr Radiol. 2012;42(12):1437-40. 14. Schatzki R. The lower esophageal ring: long term follow-up of symptomatic and asymptomatic rings. Am J Roentgenol 1963;90:805-10.  15. Smith MS. Diagnosis and Management of Esophageal Rings and Webs. Gastroenterol & Hepatol 2010;6(11):701-4. 16. Sgouros SN, Vlachogiannakos J, Karamanolis G, Vassiliadis K, Stefanidis G, Bergele C,  et al. Long-term acid suppressive therapy may prevent the relapse of lower esophageal (Schatzki’s) rings: a prospective, randomized, placebo-controlled study. Am J Gastroenterol 2005;100:1929-34.  Oluyemi & Oyedeji                       Schatzki’s Ring in a Nigerian at Gastroscopy – Case report © Sudan JMS Vol. 10, No.2. June 2015                    76   

Schatzki’s Ring in a Nigerian at Gastroscopy

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Schatzki’s Ring in a Nigerian at Gastroscopy

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