Diagnosis and treatment of esophageal ring disease - esophageal membrane

Article written by Doctor Mai Vien Phuong - Department of Examination & Internal Medicine - Vinmec Central Park International General Hospital

Most membranes and rings of the esophagus cause no symptoms. Patients may become symptomatic if the esophageal membrane or ring protrudes into the lumen sufficiently to cause esophageal stricture. Patients often present with intermittent dysphagia with solid foods.

Some patients may experience regurgitation and will present with acute dysphagia and inability to swallow saliva. In the case of Plummer-Vinson syndrome, the patient may present with a triad of dysphagia, esophageal reticular membrane, and iron deficiency anemia.
Esophageal membranes and rings are often not detected by physical examination. However, a comprehensive physical examination may indicate an associated condition. Plummer-Vinson syndrome can have skin manifestations of iron deficiency anemia including tinea capitis, glossitis, and skin infections. Skin examination may reveal bullous lesions consistent with pyoderma or bullous pemphigus.

Laboratory testing is rarely helpful in patients with suspected membrane or ring of the esophagus. Complete blood count and serum iron should be performed to look for iron-deficiency anemia.
However, patients with dysphagia should be evaluated by baryt-enhanced esophagography and/or upper gastrointestinal endoscopy. Both procedures can help differentiate between different causes of dysphagia.

Esophageal radiographs with Baryt contrast are particularly helpful in determining the cause of esophageal lumen obstruction. It can identify esophageal mesh, ring, stricture, tumor, and extraesophageal compression. An esophagogastroduodenoscopy (EGD) is often needed to confirm the diagnosis.
On EGD, the esophageal membrane appears as a thin membrane that does not extend the entire circumference of the esophagus. Esophageal rings also appear as thin membranes, but they span the entire circumference of the esophagus. EGD can also identify other causes of dysphagia including dysphagia, polyps, and tumors.
Furthermore, it may allow biopsies of lesions when malignancy is suspected. Conditions involving the esophageal ring and network that can be identified by esophagogastroduodenoscopy include eosinophilic esophagitis, hiatal hernia, and Zenker's diverticulum.

The differential diagnosis for esophageal membranes and rings is very broad and includes other causes of dysphagia. Conditions that can mimic the network and ring include angina and esophageal stricture. Achalasia presents with progressive dysphagia for solids and liquids.
The classic finding on radiographs of the oesophagus with Baryt contrast is distal dilation of the esophagus with a "bird's-beak" appearance. Esophageal obstruction presents with progressive difficulty swallowing with solids. They appear longer and have tapered, radish-like ends.

The primary initial treatment of symptomatic esophageal ring and membrane is endoscopic esophageal dilation. The goal of treatment is to relieve dysphagia and prevent symptom recurrence. Esophageal networks are often ruptured during endoscopic diagnosis of esophagitis. Esophageal dilation remains an option over a partially ruptured esophageal network.
Esophageal ring should be biopsied before dilation to rule out eosinophilic esophagitis. After dilation of the esophageal rings, patients are often treated with proton pump inhibitors (PPIs) because most of these rings are close to the gastroesophageal junction. Esophageal dilation is generally safe and effective with a low risk of complications.
The main problem with dilation is the high recurrence rate, especially when used to treat an esophageal ring. Treatment with PPIs has been shown to reduce the risk of recurrence after dilation of the esophageal rings. Recurrent symptomatic esophageal loops can be treated with repeated balloon esophagectomy followed by long-term acid suppression with PPIs. Alternative therapies include resection of the ring and membrane of the esophagus using an endoscopic electrocautery or laser knife.

Prognosis of membranes and rings of esophagus is good because most patients are asymptomatic. Symptomatic networks and rings can be treated with safe and effective esophagectomy. The main concern of therapy is the high rate of recurrence after dilation of the esophageal rings. The risk of recurrence is improved with the use of PPIs after dilation.

Image source in the article:
Radiopaedia.org, radiologyassistant.nl