Other non-neoplastic conditions

Schatzki’s ring

Schatzki’s ring is a circular ring in the distal oesophagus (Fig. 50.74), usually at the squamocolumnar junction. The cause is obscure. The core of the ring consists of variable amounts of fibrous tissue and cellular infiltrate. Most rings are incidental findings on barium examination. Some are associated with dysphagia and a single dilatation is curative.

Monilial oesophagitis

Oesophagitis due to Candida albicans is relatively common in patients taking steroids, including steroid inhalers for asthma. It may present with dysphagia or odynophagia. There may be visible thrush in the throat. Endoscopy shows numerous white plaques that cannot be moved, unlike food residues (Fig. 50.75). Biopsies are diagnostic. In severe cases a barium swallow may show dramatic mucosal ulceration and irregularity that is surprisingly similar to the appearance of oesophageal varices (Figs 50.76 and 50.77). Treatment is with nystatin lozenges or other antifungal agents.

Acquired immunodeficiency syndrome (AIDS) and the oesophagus

Dysphagia and odynophagia may occur in immune deficiency due to infection with a variety of agents including Candida, herpes simplex virus and cytomegalovirus. Similar infections may arise in immune suppression due to any other cause.

  Crohn’s disease

The oesophagus is not commonly affected by Crohn’s dis­ease. Rarely, it may be the only site of Crohn’s disease. When it occurs symptoms are severe and may be mistaken for un­usually severe reflux oesophagitis with retrosternal pain and dysphagia. Endoscopy shows extensive oesophagitis that extends much further proximally than is the case with reflux oesophagitis. Biopsies may be diagnostic, but may show only nonspecific inflammation. In severe cases a barium swallow may show deep sinuses in the oesophagus. Crohn’s oeso­phagitis responds poorly to medical treatment and resection may be required. Reconstruction can be a challenging problem in a patient with widespread Crohn’s disease at other sites.

Plummer—Vinson syndrome

Also called the Brown Kelly—Paterson syndrome or sideropenic dysphagia, this may be a pathological relic. The original descriptions are vague and poorly supported by evidence of a coherent syndrome. They describe young women with iron deficiency anaemia and dysphagia referred high in the neck. The dysphagia was said to be caused by spasm or a web in the postcricoid area. The patients were said to have an increased tendency to postcricoid cancer.

Webs certainly occur in the upper oesophagus (Fig. 50.78), but their connection with any particular syndrome is questionable. The pathology is uncertain. More recently it has been noted that there is often a patch of heterotopic gastric mucosa in the upper oesophagus. It is probably congenital and may be seen in up to 4 per cent of endoscopic examinations. Most are small, less than 1 cm2, and are easily missed. Occasional complications have been reported, such as ulceration, stricture and adenocarcinoma. Perhaps the Plummer—Vinson syndrome is a case of mistaken identity.