Schatzki ring in children and young adults: clinical and radiologic findings

Schatzki ring in pediatric and young adult patients

BACKGROUND

A Schatzki ring (SR) is an uncommon finding in children. Entities previously associated with an SR include gastroesophageal reflux (GER), hiatal hernia (HH) and eosinophilic esophagitis (EE).

OBJECTIVE

The purpose of this study was to evaluate the overall incidence of SR and the frequency of the different entities associated with SR in the pediatric population.

MATERIALS AND METHODS

All radiology reports finalized between January 2000 and December 2009 were queried to identify patients with an SR. Each study identified through the search was reviewed to confirm the presence of a SR. The patient's electronic medical record was then searched to identify all associated findings.

RESULTS

A total of 18,668 upper gastrointestinal (GI) examinations or esophagrams were performed in 15,410 children and young adults during the study period. After reviewing the reports and images, 25 patients (0.2% of all patients) were confirmed to have a SR. Of these 24 patients (96%) had HH; 10/25 (40%) had EE, and 10/25 (40%) had GER.

CONCLUSION

SR is a rare diagnosis in children. Three entities are commonly associated with a ring: HH, EE and GER. Because of the relatively high incidence of EE, endoscopy and biopsy should be considered whenever a SR is identified in a child.

Association of Schatzki ring with eosinophilic esophagitis in children

OBJECTIVE

To describe the clinicopathologic characteristics of children with Schatzki ring and to determine if Schatzki ring is associated with eosinophilic esophagitis.

METHODS

The authors report 18 adolescents with radiographically diagnosed Schatzki ring (SR). Their clinical and histologic characteristics were reviewed in a blinded fashion.

RESULTS

The mean age of the patients was 15.8 +/- 0.8 years and mean duration of symptoms was 2.6 +/- 0.4 years. By histologic criteria, two groups of patients were defined. Eight had clinical and histologic criteria of eosinophilic esophagitis (EE) and 10 of peptic esophagitis. There were no differences in the symptoms or radiographic findings in the two groups. The SR was not identified by endoscopy in any EE patient and was identified in 70% of peptic esophagitis patients. Grossly apparent mucosal features associated with EE were significantly more common in those with EE. Those with peptic esophagitis had a significantly higher acid exposure than did those with EE (12.6 +/- 2.9 v 2.0 +/- 1.1%; P < 0.01) by esophageal pH probe. Patients with peptic esophagitis responded to proton pump inhibitors and/or dilatation, whereas those with EE did not have good response and required specific therapy for EE.

CONCLUSIONS

EE may play a role in the pathogenesis of some patients with SR.

Acute food bolus impaction without stricture in children with gastroesophageal reflux

BACKGROUND/PURPOSE

This report identifies a group of children in whom severe acute food bolus impaction (AFBI) was the leading symptom of gastroesophageal reflux (GER) in the absence of stricture.

METHODS

The esophageal structure and function of 8 patients treated for AFBI requiring endoscopic removal of alimentary foreign bodies in 6 of them (up to 4 times in 1 case) were investigated by barium meal, esophagoscopy-biopsy, pH-metering, pull-through stationary manometry, and 24-hour ambulatory manometry. The results were compared with those in a group of age-matched regular refluxers (n = 14) without AFBI.

RESULTS

Six boys and 2 girls aged 108 +/- 59 months had impaction. Six children had symptoms of GER like vomiting during infancy, heartburn, or respiratory tract disease. Barium swallow ruled out stenosis in all patients and showed small hiatal hernias in 3. All had endoscopic and histologic esophagitis (moderate to severe in 6), and one had Schatzki ring. All but one (who had 8.45 mm Hg) had normal lower esophageal sphincter pressure (16.2 +/- 4.7 mm Hg, mean +/- SD), and all showed normal sphincteric relaxation. Esophageal body motility was not significantly different from that in regular refluxers except in 6 children in whom energetic distal peristalsis after reflux episodes could be seen particularly during the night. Three of them had amazingly powerful distal waves during the day and even stronger, simultaneous, wide and bizarre-shaped waves during sleep. Symptoms improved in all cases after antireflux medication. Four patients were cured after antireflux surgery.

CONCLUSIONS

AFBI is a dramatic but practically unheard of symptom of GER in children. It should be differentiated from dysphagia and reveals motor dysfunction, sometimes severe, of the esophageal body in the absence of sphincteric obstruction. Antireflux medication or surgery were uniformly successful in our patients.