Esophageal rings and webs
- Gulchin A Ergun, MD
Gulchin A Ergun, MD
- Clinical Associate Professor of Medicine
- Weill Cornell Medical College
- Peter J Kahrilas, MD
Peter J Kahrilas, MD
- Professor of Medicine
- Feinberg School of Medicine, Northwestern University
Esophageal rings and webs are thin structures that partially occlude the esophageal lumen. Patients with esophageal rings or webs are usually asymptomatic. Symptomatic patients typically present with intermittent dysphagia to solids. This topic will review the pathogenesis, clinical manifestations, diagnosis, and treatment of esophageal rings and webs. The approach to patients with dysphagia and esophageal strictures is discussed elsewhere. (See "Approach to the evaluation of dysphagia in adults" and "Management of benign esophageal strictures".)
Nonpathologic indentation of the esophagus may be caused by esophageal A and B rings and the crural diaphragm.
●A ring – The A ring is caused by normal smooth muscle contraction in the esophagus. It is located in the distal esophagus just proximal to the squamocolumnar junction corresponding to the strongest part of the lower esophageal sphincter.
●B ring – The B ring is a mucosal structure precisely at the squamocolumnar junction that is smooth and thin (≤5 mm in axial length). Owing to its location, a B ring is covered with squamous mucosa proximally and columnar epithelium distally .
●Diaphragmatic impression – Indentations in the most distal esophagus or proximal stomach that are the result of extrinsic compression by the crural diaphragm . The size of a sliding hiatal hernia is measured from the diaphragmatic impression to the A ring; this is considered abnormal when it exceeds 2 to 3 cm. When less than 2 to 3 cm, it is a normal physiologic structure known as the phrenic ampulla.
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- ASSOCIATED CONDITIONS
- Esophageal rings
- - Hiatus hernia
- - Eosinophilic esophagitis
- Esophageal webs
- - Plummer-Vinson syndrome
- - Other associated conditions
- CLINICAL PRESENTATION
- Barium esophagram
- Endoscopy and biopsy
- DIFFERENTIAL DIAGNOSIS
- Initial therapy
- - Esophageal dilation
- Safety and efficacy
- - Post-procedure acid control
- Recurrent and refractory symptoms
- - Our approach
- - Therapeutic options
- SUMMARY AND RECOMMENDATIONS