We move from cancer now into a ring.
What you want to keep in mind,
diagnostic purposes, so that you get
your questions correct, is keep
your ring separate from your webs.
Keep your rings
separate from your webs.
Begin our discussion with
what’s known as a Schatzki ring.
A Schatzki ring. Your patient, who is he or she, greater
than 40, so still relatively young but greater than 40.
Where would you find this
ring in the esophagus?
Would it be more proximal
or would it be more distal?
It would be distal.
Next, if there is a ring that is involved, then you
want to think of this as being a fixed constriction
of your esophagus in which the dysphagia would be
to solids and liquids basically at the same time.
So therefore, the description of this
clinically is called non-progressive dysphagia.
When are you thinking… So henceforth,
whenever you hear the word dysphagia,
do you understand now that you’re looking
for descriptions around that dysphagia.
Is it progressive?
Is it non-progressive?
Is it at the same time?
So on and so forth.
This is going to give you the answer.
Exacerbation with what’s known as hurried eating
and possibly development of later on, reflux.
The squamous epithelium on the upper surface,
is a columnar on the lower surface.
Where are we when we talk
about Schatzki ring?
You’re at the lower esophagus.
When you’re at the lower esophagus, then
you’re that much closer to the stomach.
You should know the general
histology of your esophagus.
So think of it as being your squamous.
Now keratinized, stratified, so on and so forth but
squamous is what you’re paying attention to, is that clear?
Whereas if you’re moving into the stomach,
then you have the columnar type.
Remember that because you’re down in the
lower esophagus, there’s every possibility
that over a long period of time that reflux
clinically is part of this syndrome.
So if reflux is also taking place simultaneously with
this ring, do you understand that now because the
ring literally behaves kind of like a panel, in which
the underside of it is being literally hit by reflux.
But the underside which used to be squamous,
is undergoing a metaplastic process.
Therefore the underside of the
ring will be columnar in nature.
Whereas the upper portion of the ring is going to be more
of your normal esophageal histology, will be squamous.
Use common sense.
Understand that you’re by the lower esophageal
sphincter, with the accompanying reflux,
the underside would be more so of the columnar nature, whereas
the upper side will be more of your squamous.
Found 6% to 14% of your population, treatment, here once
again, numerous ways of trying to dilate your esophagus.
Repeated due to recurrence.
That’s the only thing with rings because you… yes
there’s every possibility of going on to cancer,
dysplasia, anytime there’s irritation.
Anytime there’s irritation,
may go on to dysplasia.
What kind of cancer?
Do not worry about that.
What you’re paying attention to is
diagnose the ring first and once you do so,
you do everything in your power to make
sure that you dilate this esophagus.
So you are relieving the
symptoms of the patient.
For Pete’s sakes, let the patient eat.
Dilatation, but you need to
repeat it because of recurrence.
Let’s take a look at the ring here.
The ring, so this is the second time in which
we’re looking at a, endoscopic examination.
The first time I showed you endoscopic
examination, I began a discussion of strictures.
You’ll notice here on your right, you do an
upper endoscopy, you’re scoping your patient.
And you have a little camera in which
you’re looking at the esophagus.
You look at the lining of the
esophagus, there is no stricture here.
This is no varices.
This is no infection.
This is not Barrett’s tongue.
This is actually pretty
much on top of the ring.
Do you see how fleshy, and beau-…
I mean, I think this is beautiful.
I think is… For the most part this
is normal, except for the fact
that the caliber of the esophagus,
the lumen has been compromised.
You see that.
Now because of the way that the
ring is formed, now where are you?
Now take a look at the left picture with the
imaging, and you have your barium swallow.
With that barium swallow on
you’ll notice that the very bottom, so you’re moving down
to the bottom of the tube, please.
And you see an area there which
is literally become compromised.
So you’re by the lower
In other words, you’re
in the distal esophagus.
Histologically, may I
ask you a question?
On top of the ring what kind
of histology would this be?
More normal type, so there… more normal of
the esophageal type, so it’ll be squamous.
Underside if there’s reflux associated with it,
then it would be more of your columnar cells.
Esophageal rings further : This is a case where upper
endoscopy you find multiple, multiple, multiple rings.
So it looks like a beautiful column that
might be part of some kind of architectural structure,
but understand that you should not
have such rings taking place in esophagus.
Imagine here once again, the lumen has
become compromised and so therefore
making it difficult for the patient
to swallow solids and liquids.
Schatzki ring is what we talked about.
A fixed stricture, or I have to be careful,
I wouldn’t call it a stricture,
but a fixed obstruction is a better term for this.
A stricture, I showed you earlier was due to, let’s say
injury taking place in esophagus, in the lower esophagus.