Bolster technique demonstrates hidden Schatzki rings

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Caroline Jouhourian, MD from Tufts Medical Center in Boston, Massachusetts, USA discusses “Abdominal compression during endoscopy (the Bolster technique) demonstrates hidden Schatzki rings (with videos).”

Our focus was to look at means to increase the detection rate of Schatzki rings from an endoscopic approach. Literature has shown that radiographic studies such as Barium swallow studies have increased their Schatzki ring detection rate to 100% via the use of certain maneuvers such as the Valsalva maneuver. However, radiographic studies only enable diagnosis of such rings but fail to provide treatment. On the other hand, endoscopy allows us to treat these rings, yet the ability to detect them is far more limited with a sensitivity of about 58%. Thus, we aimed to find a technique similar to the Valsalva maneuver which would enable us to increase the endoscopic detection rate and not only allow us to diagnose these rings but also treat them while avoiding radiation exposure.

As concern for radiation exposure increases, we felt it was important to conduct such a study as a means to decrease the need for barium swallow studies and enable appropriate diagnosis via endoscopy. Furthermore, patients often undergo esophageal dilations for presumed Schatzki rings when presenting with dysphagia. However, a ring is often not found. Thus, we hope that by providing an inexpensive and simple maneuver, we can enable proper diagnosis and management of patients with dysphagia and provide appropriate clinical treatment.

Our study found that there was a 13% increase in endoscopic detection rate of Schatzki rings when the Bolster technique was used. This technique requires steady epigastric pressure for a few seconds to expose the ring hidden in the hiatal sac. We looked at 30 patients with dysphagia and known prior Schatzki rings, diagnosed either via radiographic imaging (barium swallow study or gastrointestinal series) or endoscopy. Other causes of dysphagia were ruled out. Twenty-six of these patients had detectable rings without the Bolster technique, while the other 4 required the use of the Bolster technique to expose the ring.

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A, Standard endoscopy with a normal gastroesophageal junction. B, Identified Schatzki ring with the Bolster technique.

These findings suggest that perhaps, much like radiographic studies using the Valsalva maneuver, we may be able to increase the endoscopic detection rate of Schatzki rings. This would limit the need for diagnostic radiographic exams that expose patients to radiation and allow us to proceed directly to endoscopy where diagnosis and treatment can be performed effectively.

Additionally, we would be interested in assessing long-term outcomes of patients. Prior, patients presumably had dysphagia secondary to Schatzki rings and thus would undergo empiric esophageal dilation without a diagnosis. Perhaps, by properly diagnosing such patients, we can treat them more accurately by either ablating the ring or looking for other causes of dysphagia such as motility disorders.  This would require a larger prospective cohort.

Read the abstract online.

The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.

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