At times, I find it very hard to swallow. Last night, I could not get a piece of steak to go down. Any ideas what the problem could be?

M.M.

Gastroenterologists often see patients who experience episodes of difficulty in swallowing solid foods, such as steak. In most cases, the problem stems from an abnormality known as a Schatzki's ring. This ring is basically a mild narrowing caused by fibrous scar tissue in the lower esophagus. The origin of this ring is in dispute. Some doctors think it is present from birth and only causes problems in later years. However, most gastroenterologists believe that it is a result of chronic gastroesophageal reflux (GERD). The acid reflux may not be severe enough to cause heartburn or other discomfort, but it may silently trigger inflammation in the lower esophagus, leading to the formation of a scar-tissue ring.

A Schatzki's ring is most often detected during tests (such as an upper endoscopy or a radiographic upper GI barium series) that are being done for unrelated digestive complaints. Most of the rings found do not cause symptoms and need no therapy.

In those patients who do experience problems, the most common symptom is intermittent episodes of difficulty in swallowing (dysphagia). Since the ring is only a minor narrowing of the esophagus, most food particles and all liquids easily pass down the esophagus. However, large pieces of solid food, such as steak, chicken or bread, occasionally get stuck in the esophagus at the ring. Patients can sometimes drink liquids to move the food past the ring, or they may vomit up the piece of food. In some cases, the food gets stuck and cannot be dislodged. Patients in this situation often come to the emergency room, where an endoscopy is done to make the diagnosis and get the food unstuck. When a Schatzki's ring is discovered in this fashion, the problem is sometimes called "steakhouse syndrome."

The therapy for a Schatzki's ring is dilation, or stretching, of the ring to break it and prevent further episodes. Dilation involves sedating the patient, placing a flexible tube in the esophagus and passing the tube down to the stomach.

It is important to keep in mind that although difficulty in swallowing steak or other solid food is very consistent with a Schatzki's ring, other diagnoses must be ruled out. These include esophageal stricture (a more severe narrowing, usually because of reflux) or esophageal cancer. Thus, an upper endoscopy is an important test to perform in any patient with dysphagia. You should get a referral to a gastroenterologist to discuss your symptoms.