01OverviewDefinition, clinical context and the essential points that orientate the chapter.
Both lesions narrow the lumen but their histories differ. Peptic inflammation heals with fibrosis, forming a longer distal narrowing accompanied by heartburn or oesophagitis. A Schatzki ring is short and circumferential, producing sudden intermittent obstruction to large solids despite normal eating between attacks. Either may coexist with hiatus hernia, and eosinophilic oesophagitis can create rings or strictures at any level.
Endoscopy defines location, length, diameter, mucosal abnormality and ability to traverse the lesion. Biopsy is essential because cancer may look deceptively smooth, and eosinophilic disease may have subtle or normal-appearing mucosa. Contrast imaging helps with a very tight, proximal, long, angulated or complex stricture before intervention. Dilation is a controlled tear or stretch and therefore carries bleeding and perforation risk.
Successful treatment restores a usable lumen while controlling the cause. Peptic strictures need effective acid suppression and adherence review. Eosinophilic inflammation needs diet, PPI or topical steroid treatment even after mechanical relief. Recurrent dysphagia prompts reassessment rather than endless empirical dilation: incomplete acid control, missed malignancy, eosinophilic remodelling, motility disease and procedural fibrosis all change the next plan.
Key points
- Peptic strictures usually lie distally after chronic reflux injury and cause gradually progressive solid-food dysphagia.
- A Schatzki ring is a thin mucosal ring at the squamocolumnar junction and often causes intermittent dysphagia to bread or meat.
- Biopsy every stricture before dilation where safely possible to exclude malignancy and eosinophilic oesophagitis.
- Endoscopic dilation should use wire-guided bougies or balloons with a planned diameter progression, explicit perforation consent and post-procedure safety checks.
- A symptomatic Schatzki ring is treated by dilation to rupture the ring, while asymptomatic incidental rings need no intervention.
- Sustained PPI treatment after peptic-stricture dilation reduces recurrent acid injury; recurrent rings or impactions require assessment for eosinophilic disease.
02AetiologyUnderlying causes, associations and risk factors, with why each one matters.
Chronic reflux injury
Repeated gastric acid exposure causes distal oesophageal ulceration followed by collagen deposition and contraction, producing a peptic stricture during mucosal healing.
Mucosal ring formation
A Schatzki ring is a thin circumferential narrowing at the squamocolumnar junction, associated variably with reflux and eosinophilic inflammation.
03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.
- 1Progressive fibrotic calibre loss
Collagen deposition contracts the distal lumen, so large solids fail first and increasingly soft foods obstruct as narrowing advances.
- 2Intermittent bolus mismatch
A fixed thin ring permits ordinary small boluses but traps poorly chewed meat or bread that exceeds its diameter.
- 3Upstream retention
Food and secretions collect above severe narrowing, causing regurgitation, aspiration, mucosal pressure injury and complete obstruction.
04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.
Steadily progressive solid-food dysphagia with distal reflux injury suggests fibrotic peptic stricture.
Intermittent meat or bread impaction with full recovery between events is typical of a lower-oesophageal ring.
Rapid progression, weight loss, bleeding or an irregular shouldered lesion requires tissue diagnosis before a benign label.
Young age, atopy, recurrent bolus impaction and multiple rings demand multi-level biopsies.
Post-procedure pain with tachycardia, dyspnoea or fever is perforation until assessed, not expected discomfort.
05InvestigationsWhat to request, why it matters and how to interpret it.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
Upper-GI endoscopy with biopsyFirst step - Why
- Diagnose the narrowing and exclude malignant or eosinophilic causes.
- Interpretation and limitations
- Record distance, length, diameter and traversability; obtain histology before dilation when safe, and repeat sampling when clinical suspicion persists despite a benign result.
- 02
Barium swallow - Why
- Map a complex stricture and show a thin ring or proximal dilatation.
- Interpretation and limitations
- Contrast can define length and angulation before dilation, but a benign contour does not eliminate the need for endoscopic biopsy.
- 03
Multi-level oesophageal biopsies - Why
- Detect eosinophilic inflammation when rings, impactions or atopy are present.
- Interpretation and limitations
- Samples from more than one level improve sensitivity because eosinophils are patchy; acid suppression and treatment timing affect interpretation.
- 04
Post-dilation observation - Why
- Detect early bleeding, aspiration or perforation.
- Interpretation and limitations
- New persistent pain, tachycardia, breathlessness, fever or crepitus requires urgent investigation rather than routine discharge.
- 05
Recurrent-dysphagia review - Why
- Identify why mechanical benefit did not last.
- Interpretation and limitations
- Re-examine acid control, histology, stricture morphology and motility; repeated dilation without revisiting cause compounds risk.
06Differential diagnosisRealistic alternatives and the features that help distinguish them.
Oesophageal carcinoma
Malignant infiltration produces progressive luminal narrowing, weight loss and irregular or friable mucosa, so endoscopic appearances must be sampled and malignancy excluded histologically.
Eosinophilic oesophagitis
Patchy eosinophil-predominant inflammation causes oedema, fixed rings and fibrosis, particularly in people with atopy, recurrent food impaction or subtle endoscopic change.
Achalasia
Failed junction relaxation causes liquid and solid dysphagia with no fixed mucosal narrowing, confirmed by high-resolution manometry after endoscopy.
07ManagementImmediate care, first-line treatment, alternatives and escalation.
01Endoscopic treatmentDilate a benign peptic strictureFirst stepBiopsy confirms benign reflux-related fibrosis and the patient cannot tolerate normal solids.+
- 1Explain graded dilation, likely need for more than one session, perforation risk and the importance of acid control.
- 2Use a wire-guided bougie or through-the-scope balloon along a known path and plan cautious serial sessions for a tight or complex stricture rather than forcing a large increase in one session.
- 3Start or optimise a licensed PPI regimen and address reflux drivers after mechanical treatment.
- 4Verify swallowing improvement and give precise emergency advice for chest pain, dyspnoea, fever or haematemesis.
02Intermittent ringTreat the symptom, inspect the causeA lower-oesophageal ring is found after recurrent meat impaction.+
- 1Biopsy the oesophagus for eosinophilic inflammation and inspect the junction and stomach.
- 2For a symptomatic Schatzki ring, perform a single graded dilation to a relatively large 16–20 mm diameter to rupture the ring; this differs from the cautious staged approach used for a tight complex stricture.
- 3Treat coexisting reflux or eosinophilic disease rather than regarding dilation as complete care.
- 4Review recurrence, adaptation and nutritional avoidance after recovery.
03Unexpected irregularityStop the benign pathwayA presumed peptic stricture is irregular and bleeds on contact.+
- 1Obtain multiple targeted biopsies and do not force dilation through an uncharacterised cancer risk.
- 2Stage and discuss through the oesophago-gastric cancer multidisciplinary pathway if malignant.
- 3Support nutrition without placing access blindly through the lesion.
- 4Confirm the pathology has been reviewed and communicated promptly.
Key medicines and prescribing safety1 treatment · regimens, roles and cautions+
Omeprazole after peptic-stricture dilation
After dilation of a reflux-mediated peptic stricture, continue long-term full-dose omeprazole: 20 mg orally once daily is the usual full dose, while 40 mg once daily is the severe-oesophagitis full dose after an eight-week healing course. This post-dilation indication should not be reduced automatically to intermittent or on-demand therapy.Swallow the gastro-resistant tablet whole with water and do not chew or crush it. Nelfinavir is contraindicated and concomitant clopidogrel is discouraged; hepatic impairment may require a lower dose. During prolonged therapy, periodically review the continuing indication and individual risk of hypomagnesaemia, reduced vitamin B12 absorption, enteric infection and fracture; investigate or monitor according to symptoms and risk factors rather than ordering every test for everyone or stopping indicated post-dilation maintenance automatically. Reassess recurrent dysphagia for restricture, malignancy or eosinophilic disease. A PPI may itself induce remission in eosinophilic oesophagitis, but response requires disease-specific clinical and histological assessment.
08ComplicationsImportant consequences, why they occur and why they matter clinically.
Food bolus obstruction
An impacted food bolus can prevent saliva passage, provoke aspiration or pressure injury and require urgent therapeutic endoscopy after airway assessment.
Dilation perforation
Dilation or a deeply impacted bolus can tear through the oesophageal wall, leading to mediastinal contamination, pleural infection and systemic sepsis.
Recurrent stricture
Persistent reflux or untreated eosinophilic inflammation drives renewed collagen deposition, recurrent fibrosis and repeated loss of lumen despite technically successful dilation.
09Monitoring and follow-upTreatment response, safety checks and longer-term review.
- Track tolerated texture, impactions and weight after each dilation rather than recording scope passage alone.
- Review histology before the next session and reconcile eosinophilic or malignant findings with the treatment plan.
- Check PPI adherence, timing and symptom control in peptic disease.
- After dilation, provide immediate contact instructions for perforation or bleeding symptoms.
- Reinvestigate recurrent dysphagia before repeating a familiar procedure automatically.
10Special situationsVariants, exceptions and circumstances that change the usual approach.
Biopsy changes the procedure
A benign-looking stricture can contain cancer, so histology protects against inappropriate repeated dilation.
A ring can be intermittent
The lumen may pass a slim endoscope even though poorly chewed meat repeatedly obstructs during real meals.
Mechanical and inflammatory care combine
Widening treats calibre; acid or eosinophilic treatment reduces the biological driver of recurrence.
Complex geometry increases risk
Long, angulated, very narrow and post-radiation strictures require slower expert dilation and sometimes fluoroscopic guidance.
11Common pitfallsFrequent interpretation and management errors.
- 01
Dilating an unbiopsied progressive stricture because reflux is documented.
- 02
Calling recurrent rings harmless and omitting eosinophilic biopsies.
- 03
Increasing diameter aggressively in one session despite complex anatomy.
- 04
Discharging after new persistent chest pain without considering perforation.