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article-21616_41	Familial Short Stature -- Treatment / Management	The studies conducted thus far on rGH therapy in SS, which have included children with FSS, have had several limitations like insufficient numbers, lack of control groups, different dosages of rGH, and undiagnosed conditions producing pathological SS.	Familial Short Stature -- Treatment / Management. The studies conducted thus far on rGH therapy in SS, which have included children with FSS, have had several limitations like insufficient numbers, lack of control groups, different dosages of rGH, and undiagnosed conditions producing pathological SS.
article-21616_42	Familial Short Stature -- Treatment / Management	Given the lack of definitive evidence of the benefits of rGH in FSS, especially a lack of benefit in self-esteem and/or quality of life, the FDA has not approved treatment with rGH for this indication. The treatment cost is prohibitive, and the response in both familial and non-familial ISS is very unpredictable. More well-designed studies are needed in this area, and any attempt to use GH for FSS should be considered as "off-label." Recombinant IGF1 is useful in IGF1 deficiency due to gene deletions or mutations.	Familial Short Stature -- Treatment / Management. Given the lack of definitive evidence of the benefits of rGH in FSS, especially a lack of benefit in self-esteem and/or quality of life, the FDA has not approved treatment with rGH for this indication. The treatment cost is prohibitive, and the response in both familial and non-familial ISS is very unpredictable. More well-designed studies are needed in this area, and any attempt to use GH for FSS should be considered as "off-label." Recombinant IGF1 is useful in IGF1 deficiency due to gene deletions or mutations.
article-21616_43	Familial Short Stature -- Treatment / Management	Attention must be given to detect psychological problems in children with FSS, which may be the result of teasing, bullying, and discrimination by peers as well as society. Although it is generally believed that such problems are universal in children with SS, there may be a selection bias. This is because the majority of the data are from pediatric clinics, where children with problems are seen. In the Wessex growth study, a large sample of community-dwelling children whose only problem was SS was studied. Results did not show increased cognitive, psychosocial, or maladaptive dysfunction, thus dispelling the myth that SS universally has psychosocial issues. [26]	Familial Short Stature -- Treatment / Management. Attention must be given to detect psychological problems in children with FSS, which may be the result of teasing, bullying, and discrimination by peers as well as society. Although it is generally believed that such problems are universal in children with SS, there may be a selection bias. This is because the majority of the data are from pediatric clinics, where children with problems are seen. In the Wessex growth study, a large sample of community-dwelling children whose only problem was SS was studied. Results did not show increased cognitive, psychosocial, or maladaptive dysfunction, thus dispelling the myth that SS universally has psychosocial issues. [26]
article-21616_44	Familial Short Stature -- Differential Diagnosis	The most important and equally common condition that has to be differentiated from familial short stature (FSS) is CDGP. In most cases, the differentiation is simple. Children with CDGP resemble FSS because they have normal birth length and weight; they have a "catch down growth" that crosses percentiles and have a normal growth rate. However, they differ since they are slightly above the growth curve, develop puberty later, and have a bone age that is delayed by at least two years. The final height in CDGP is much greater than that found in FSS: Height velocity or the rate of linear growth can help to differentiate the causes: Normal height velocity: familial short stature and CDGP. Slow height velocity: growth hormone deficiency. GSS: final height that is below the 3rd percentile. CDGP: final height in the normal range.	Familial Short Stature -- Differential Diagnosis. The most important and equally common condition that has to be differentiated from familial short stature (FSS) is CDGP. In most cases, the differentiation is simple. Children with CDGP resemble FSS because they have normal birth length and weight; they have a "catch down growth" that crosses percentiles and have a normal growth rate. However, they differ since they are slightly above the growth curve, develop puberty later, and have a bone age that is delayed by at least two years. The final height in CDGP is much greater than that found in FSS: Height velocity or the rate of linear growth can help to differentiate the causes: Normal height velocity: familial short stature and CDGP. Slow height velocity: growth hormone deficiency. GSS: final height that is below the 3rd percentile. CDGP: final height in the normal range.
article-21616_45	Familial Short Stature -- Differential Diagnosis	The majority of children born small for gestational age (SGA) will catch up with height and weight during the first two years of life. A few, however, fail to catch up and remain short. This type of individual can be distinguished by obtaining a careful history. Other causes of proportionate SS are Turner, Noonan, and Russell-Silver syndromes are differentiated by various associated physical findings and investigations. The children with FSS have an adequate nutritional status and are easily distinguished from states of malnutrition, where weight is affected more than height. Chronic systemic illnesses have features peculiar to their condition and can be easily distinguished from FSS; since children with FSS are healthy and active. Hypothyroidism may present with SS; but have a delayed bone age, deceleration of growth velocity, and other characteristic findings. Thyroid function tests will help confirm the diagnosis.	Familial Short Stature -- Differential Diagnosis. The majority of children born small for gestational age (SGA) will catch up with height and weight during the first two years of life. A few, however, fail to catch up and remain short. This type of individual can be distinguished by obtaining a careful history. Other causes of proportionate SS are Turner, Noonan, and Russell-Silver syndromes are differentiated by various associated physical findings and investigations. The children with FSS have an adequate nutritional status and are easily distinguished from states of malnutrition, where weight is affected more than height. Chronic systemic illnesses have features peculiar to their condition and can be easily distinguished from FSS; since children with FSS are healthy and active. Hypothyroidism may present with SS; but have a delayed bone age, deceleration of growth velocity, and other characteristic findings. Thyroid function tests will help confirm the diagnosis.
article-21616_46	Familial Short Stature -- Differential Diagnosis	Cushing syndrome is a rare cause of SS. In this case, children are sick, have distinguishing physical findings, delayed bone age, growth deceleration, and typical laboratory test results.	Familial Short Stature -- Differential Diagnosis. Cushing syndrome is a rare cause of SS. In this case, children are sick, have distinguishing physical findings, delayed bone age, growth deceleration, and typical laboratory test results.
article-21616_47	Familial Short Stature -- Differential Diagnosis	Classical GH deficiency has physical features of the condition, symptoms, signs of deficiencies of other pituitary hormones, delayed bone age, very significant SS, growth deceleration that extends from onset of the disease and continues throughout, a low IGF1, IGFBP3, and poor GH responses to stimulation tests. It is when GH deficiency is partial or incomplete that distinguishing it from FSS or CDGP becomes difficult. Here, the GH stimulation tests are not sensitive enough to make that determination. [21]	Familial Short Stature -- Differential Diagnosis. Classical GH deficiency has physical features of the condition, symptoms, signs of deficiencies of other pituitary hormones, delayed bone age, very significant SS, growth deceleration that extends from onset of the disease and continues throughout, a low IGF1, IGFBP3, and poor GH responses to stimulation tests. It is when GH deficiency is partial or incomplete that distinguishing it from FSS or CDGP becomes difficult. Here, the GH stimulation tests are not sensitive enough to make that determination. [21]
article-21616_48	Familial Short Stature -- Differential Diagnosis	In pre-pubertal boys older than 11 years and girls older than ten years, it is important to prime with sex steroids before GH stimulation studies; otherwise, many children with CDGP (and some with combined FSS and CDGP) may be misdiagnosed as GH deficiency and unnecessarily exposed to rGH therapy. There is a significant difference in the GH response to stimulation when sex-steroid priming is employed. Either 2 mg of 17-beta-estradiol (for both boys and girls) orally two days before the test or testosterone (for boys) 50 mg intramuscularly a day before the procedure is recommended. Obesity blunts GH responses to stimulation testing. Many normal children also show ambiguous responses following a single stimulation procedure. Therefore, it is important to test with two modalities for accurate classification. [21] [27]	Familial Short Stature -- Differential Diagnosis. In pre-pubertal boys older than 11 years and girls older than ten years, it is important to prime with sex steroids before GH stimulation studies; otherwise, many children with CDGP (and some with combined FSS and CDGP) may be misdiagnosed as GH deficiency and unnecessarily exposed to rGH therapy. There is a significant difference in the GH response to stimulation when sex-steroid priming is employed. Either 2 mg of 17-beta-estradiol (for both boys and girls) orally two days before the test or testosterone (for boys) 50 mg intramuscularly a day before the procedure is recommended. Obesity blunts GH responses to stimulation testing. Many normal children also show ambiguous responses following a single stimulation procedure. Therefore, it is important to test with two modalities for accurate classification. [21] [27]
article-21616_49	Familial Short Stature -- Prognosis	Children with familial short stature (FSS) will attain their predicted height when the mid-parental height is taken into consideration but will end up as short adults compared to others of the same age, gender, and population.	Familial Short Stature -- Prognosis. Children with familial short stature (FSS) will attain their predicted height when the mid-parental height is taken into consideration but will end up as short adults compared to others of the same age, gender, and population.
article-21616_50	Familial Short Stature -- Complications	There are no complications if an expectant approach is adopted in FSS. Psychological problems should be diligently sought and managed early, and efficiently; otherwise, it may affect the child's psyche, school performance, and cause low self-esteem.	Familial Short Stature -- Complications. There are no complications if an expectant approach is adopted in FSS. Psychological problems should be diligently sought and managed early, and efficiently; otherwise, it may affect the child's psyche, school performance, and cause low self-esteem.
article-21616_51	Familial Short Stature -- Consultations	Familial short stature is caused by multiple factors, and its effects are not only on the phenotype; rather, they are on the psyche of the patients and their families as well. Consequently, it is imperative to take on board different disciplines to enhance patient outcomes. Following are the mandatory consultations: Primary care (family medicine, pediatrics) Pediatric endocrinology Laboratory medicine Clinical genetics and molecular medicine Clinical psychology	Familial Short Stature -- Consultations. Familial short stature is caused by multiple factors, and its effects are not only on the phenotype; rather, they are on the psyche of the patients and their families as well. Consequently, it is imperative to take on board different disciplines to enhance patient outcomes. Following are the mandatory consultations: Primary care (family medicine, pediatrics) Pediatric endocrinology Laboratory medicine Clinical genetics and molecular medicine Clinical psychology
article-21616_52	Familial Short Stature -- Deterrence and Patient Education	Education of the family coping with classic familial short stature (FSS) is extremely important to avoid unnecessary investigations and treatments. They should be made to understand why short parents have short children. Simple terminology to explain the genetic nature of the condition should be employed. For children exhibiting combined FSS and CDGP, the SS may be more profound, and families should be counseled to engage in investigations to exclude pathological SS. At the same time, if evaluation implicates monogenic disorders that warrant more extensive testing, the appropriate approach should be pursued. The services of a clinical psychologist will sometimes be necessary. Such a professional can play a vital role in helping the child with FSS and the family cope with unforeseen life experiences.	Familial Short Stature -- Deterrence and Patient Education. Education of the family coping with classic familial short stature (FSS) is extremely important to avoid unnecessary investigations and treatments. They should be made to understand why short parents have short children. Simple terminology to explain the genetic nature of the condition should be employed. For children exhibiting combined FSS and CDGP, the SS may be more profound, and families should be counseled to engage in investigations to exclude pathological SS. At the same time, if evaluation implicates monogenic disorders that warrant more extensive testing, the appropriate approach should be pursued. The services of a clinical psychologist will sometimes be necessary. Such a professional can play a vital role in helping the child with FSS and the family cope with unforeseen life experiences.
article-21616_53	Familial Short Stature -- Pearls and Other Issues	Children with GSS will ultimately attain a final height that is below the 3rd percentile. Whereas children with CDGP will achieve a final height in the normal range. However, this differentiation may not be absolute. The height velocity is normal in children with familial (or genetic) short stature. But it is slowed in children presenting with GH or thyroid deficiencies.	Familial Short Stature -- Pearls and Other Issues. Children with GSS will ultimately attain a final height that is below the 3rd percentile. Whereas children with CDGP will achieve a final height in the normal range. However, this differentiation may not be absolute. The height velocity is normal in children with familial (or genetic) short stature. But it is slowed in children presenting with GH or thyroid deficiencies.
article-21616_54	Familial Short Stature -- Enhancing Healthcare Team Outcomes	Quite often, in practice, the primary care providers must be familiar with the entity of familial short stature (FSS) as it is frequently encountered. Indeed, they should be prepared to try to convince anxious parents that rGH treatment has not been approved for FSS. This is in contrast to some cases of ISS, where some studies have (not conclusively) demonstrated benefit. [22] [23] [24] [Level 2]	Familial Short Stature -- Enhancing Healthcare Team Outcomes. Quite often, in practice, the primary care providers must be familiar with the entity of familial short stature (FSS) as it is frequently encountered. Indeed, they should be prepared to try to convince anxious parents that rGH treatment has not been approved for FSS. This is in contrast to some cases of ISS, where some studies have (not conclusively) demonstrated benefit. [22] [23] [24] [Level 2]
article-21616_55	Familial Short Stature -- Enhancing Healthcare Team Outcomes	The laboratory medicine personnel should be provided with a summary of the child's clinical history. Coordination between the laboratory staff and the provider will help conduct tests such as GH stimulation more accurately.	Familial Short Stature -- Enhancing Healthcare Team Outcomes. The laboratory medicine personnel should be provided with a summary of the child's clinical history. Coordination between the laboratory staff and the provider will help conduct tests such as GH stimulation more accurately.
article-21616_56	Familial Short Stature -- Enhancing Healthcare Team Outcomes	Occasionally, genetic tests may be needed, and extensive counseling on testing, avoidance of unnecessary procedures, and adaptation to the environment will need inter-professional communication with the provider, laboratory, nurses, and clinical psychologists to improve outcomes and enhance team performance.	Familial Short Stature -- Enhancing Healthcare Team Outcomes. Occasionally, genetic tests may be needed, and extensive counseling on testing, avoidance of unnecessary procedures, and adaptation to the environment will need inter-professional communication with the provider, laboratory, nurses, and clinical psychologists to improve outcomes and enhance team performance.
article-21616_57	Familial Short Stature -- Review Questions	Access free multiple choice questions on this topic. Click here for a simplified version. Comment on this article.	Familial Short Stature -- Review Questions. Access free multiple choice questions on this topic. Click here for a simplified version. Comment on this article.
article-28746_0	Schatzki Ring -- Continuing Education Activity	A Schatzki ring is a circular membrane of mucosa and submucosa that forms at the squamocolumnar junction of the distal esophagus. Schatzki rings appear as thin membranous structures that do not contain any muscularis propria. The upper surface is covered with squamous epithelium, and the lower surface is covered with columnar epithelium. Schatzki rings are always associated with hiatal hernias. This activity describes the pathophysiology, etiology, presentation, and management of Schatzki rings and highlights the role of the interprofessional team in caring for patients with this condition.	Schatzki Ring -- Continuing Education Activity. A Schatzki ring is a circular membrane of mucosa and submucosa that forms at the squamocolumnar junction of the distal esophagus. Schatzki rings appear as thin membranous structures that do not contain any muscularis propria. The upper surface is covered with squamous epithelium, and the lower surface is covered with columnar epithelium. Schatzki rings are always associated with hiatal hernias. This activity describes the pathophysiology, etiology, presentation, and management of Schatzki rings and highlights the role of the interprofessional team in caring for patients with this condition.
article-28746_1	Schatzki Ring -- Continuing Education Activity	Objectives: Identify the etiology of Schatzki rings. Describe the presentation of a patient with a Schatzki ring. Review the treatment options for Schatzki rings. Explain the importance of optimizing care coordination amongst interprofessional team members to improve outcomes for patients with Schatzki rings. Access free multiple choice questions on this topic.	Schatzki Ring -- Continuing Education Activity. Objectives: Identify the etiology of Schatzki rings. Describe the presentation of a patient with a Schatzki ring. Review the treatment options for Schatzki rings. Explain the importance of optimizing care coordination amongst interprofessional team members to improve outcomes for patients with Schatzki rings. Access free multiple choice questions on this topic.
article-28746_2	Schatzki Ring -- Introduction	Richard Schatzki was a renowned radiologist who described a ring-like structure in patients with dysphagia in articles from 1953 to 1963, and that structure would later bear his name. Schatzki ring is described as a circular membrane of mucosa and submucosa that is seen at the squamocolumnar junction of the distal esophagus. It appears as a thin membranous structure that does not contain any muscularis propria. It has an upper surface that is covered with squamous epithelium and a lower surface that is covered with columnar epithelium and is always associated with a hiatal hernia. [1] [2] [3]	Schatzki Ring -- Introduction. Richard Schatzki was a renowned radiologist who described a ring-like structure in patients with dysphagia in articles from 1953 to 1963, and that structure would later bear his name. Schatzki ring is described as a circular membrane of mucosa and submucosa that is seen at the squamocolumnar junction of the distal esophagus. It appears as a thin membranous structure that does not contain any muscularis propria. It has an upper surface that is covered with squamous epithelium and a lower surface that is covered with columnar epithelium and is always associated with a hiatal hernia. [1] [2] [3]
article-28746_3	Schatzki Ring -- Etiology	As stated previously, Schatzki ring is associated with a hiatal hernia. Gastroesophageal reflux has been thought of as causing the ring. It has been postulated that the creation of a Schatzki ring is the body’s response to frequent acid exposure and a natural way of preventing the development of Barrett esophagus. Studies have shown that Barrett esophagus is less common when a Schatzki ring is present, especially long-segment Barrett’s esophagus. [4] [5] [6] Eosinophilic esophagitis has been associated with Schatzki ring. [7]	Schatzki Ring -- Etiology. As stated previously, Schatzki ring is associated with a hiatal hernia. Gastroesophageal reflux has been thought of as causing the ring. It has been postulated that the creation of a Schatzki ring is the body’s response to frequent acid exposure and a natural way of preventing the development of Barrett esophagus. Studies have shown that Barrett esophagus is less common when a Schatzki ring is present, especially long-segment Barrett’s esophagus. [4] [5] [6] Eosinophilic esophagitis has been associated with Schatzki ring. [7]
article-28746_4	Schatzki Ring -- Epidemiology	Schatzki ring is found in 6% to 14% of barium radiographs done routinely. It is noted to be the most common cause of episodic dysphagia for solids and food impactions in adults. There are no known population studies to suggest how common it is among the general population.	Schatzki Ring -- Epidemiology. Schatzki ring is found in 6% to 14% of barium radiographs done routinely. It is noted to be the most common cause of episodic dysphagia for solids and food impactions in adults. There are no known population studies to suggest how common it is among the general population.
article-28746_5	Schatzki Ring -- Pathophysiology	As a Schatzki ring develops, it causes narrowing of the distal esophageal lumen that creates an intrinsic mechanical disorder. This will result in symptoms of dysphagia or complications like food impaction when the diameter becomes so small food is unable to pass. The ring does not cause symptoms until it reaches a diameter that obstructs food from passing. Richard Schatski developed the “Schatzki rule,” which was that a ring under 13 mm will always have symptoms, and a ring larger than 25 mm will always be asymptomatic. In cases where food becomes stuck, patients can develop odynophagia or chest pain. [8] [9] [10]	Schatzki Ring -- Pathophysiology. As a Schatzki ring develops, it causes narrowing of the distal esophageal lumen that creates an intrinsic mechanical disorder. This will result in symptoms of dysphagia or complications like food impaction when the diameter becomes so small food is unable to pass. The ring does not cause symptoms until it reaches a diameter that obstructs food from passing. Richard Schatski developed the “Schatzki rule,” which was that a ring under 13 mm will always have symptoms, and a ring larger than 25 mm will always be asymptomatic. In cases where food becomes stuck, patients can develop odynophagia or chest pain. [8] [9] [10]
article-28746_6	Schatzki Ring -- Histopathology	As previously described, there is squamous epithelium above the ring and columnar epithelium below it. This differentiates it from esophageal webs, which have squamous (esophageal) epithelium on both sides. In initial studies, it was described as being triangle-shaped on cross-section and formed by a core of connective tissue with an overgrowth of muscularis mucosa and smooth muscle fibers creating an annular band.	Schatzki Ring -- Histopathology. As previously described, there is squamous epithelium above the ring and columnar epithelium below it. This differentiates it from esophageal webs, which have squamous (esophageal) epithelium on both sides. In initial studies, it was described as being triangle-shaped on cross-section and formed by a core of connective tissue with an overgrowth of muscularis mucosa and smooth muscle fibers creating an annular band.
article-28746_7	Schatzki Ring -- History and Physical	Most Schatzki rings do not cause symptoms, but the main symptom that does occur is dysphagia and can result in acute dysphagia as a result of food impaction. Symptoms are commonly associated with not very well-chewed meat and are sometimes described as food sticking in the chest, which has been referred to as “Steakhouse syndrome." Symptoms are less commonly associated with globus, which is the sensation of a “lump” or “blockage” between the cricoid and sternal notch. In the case of food impaction, patients can present with odynophagia.	Schatzki Ring -- History and Physical. Most Schatzki rings do not cause symptoms, but the main symptom that does occur is dysphagia and can result in acute dysphagia as a result of food impaction. Symptoms are commonly associated with not very well-chewed meat and are sometimes described as food sticking in the chest, which has been referred to as “Steakhouse syndrome." Symptoms are less commonly associated with globus, which is the sensation of a “lump” or “blockage” between the cricoid and sternal notch. In the case of food impaction, patients can present with odynophagia.
article-28746_8	Schatzki Ring -- History and Physical	Key questions to ask pertaining to the location of discomfort in swallowing, which would be expected to be subxiphoid (lower chest/upper abdominal area), and whether symptoms are worse with solids or liquids or both. The extent of symptoms depends on the diameter of the ring, and the largest diameter with symptoms would be less than 25 mm according to the “Schatzki rule.”	Schatzki Ring -- History and Physical. Key questions to ask pertaining to the location of discomfort in swallowing, which would be expected to be subxiphoid (lower chest/upper abdominal area), and whether symptoms are worse with solids or liquids or both. The extent of symptoms depends on the diameter of the ring, and the largest diameter with symptoms would be less than 25 mm according to the “Schatzki rule.”
article-28746_9	Schatzki Ring -- Evaluation	Once a patient presents with symptoms suggesting a Schatzki ring, the initial study in evaluation is a barium esophagram. If significant enough, it will show an area of the distal esophagus that is less distensible, creating a ring-like structure on radiographic images. Often, a patient is asked to swallow a substance like a marshmallow or a barium tablet to assess the diameter of the ring. This is often followed by an endoscopy to evaluate the ring and then treat patients with symptoms. If the finding is incidental and the patient has no symptoms, treatment is not necessary until symptoms occur. However, endoscopy is still recommended to rule out other causes of strictures, especially esophageal malignancy. Biopsies should be performed if there is an irregular Z-line at the gastroesophageal junction to assess for Barrett esophagus. Biopsies of the ring can be done as a treatment method as well. [11] [12]	Schatzki Ring -- Evaluation. Once a patient presents with symptoms suggesting a Schatzki ring, the initial study in evaluation is a barium esophagram. If significant enough, it will show an area of the distal esophagus that is less distensible, creating a ring-like structure on radiographic images. Often, a patient is asked to swallow a substance like a marshmallow or a barium tablet to assess the diameter of the ring. This is often followed by an endoscopy to evaluate the ring and then treat patients with symptoms. If the finding is incidental and the patient has no symptoms, treatment is not necessary until symptoms occur. However, endoscopy is still recommended to rule out other causes of strictures, especially esophageal malignancy. Biopsies should be performed if there is an irregular Z-line at the gastroesophageal junction to assess for Barrett esophagus. Biopsies of the ring can be done as a treatment method as well. [11] [12]
article-28746_10	Schatzki Ring -- Treatment / Management	The goal of treatment is to increase the diameter of the ring to allow unobstructed passage through the esophagus. Breaking the ring most often does this. Methods of doing so include dilation and/or biopsies of the ring with biopsy forceps.	Schatzki Ring -- Treatment / Management. The goal of treatment is to increase the diameter of the ring to allow unobstructed passage through the esophagus. Breaking the ring most often does this. Methods of doing so include dilation and/or biopsies of the ring with biopsy forceps.
article-28746_11	Schatzki Ring -- Treatment / Management	Dilation can be done with bougies or pneumonic balloons. Bougies can be used with a guidewire (Savory dilators), without a guidewire (Maloney dilators), or with a pneumonic balloon dilator. Dilation with a bougie is done without direct visualization of the esophagus, but guidewire placement is done with direct visualization during endoscopy showing the path of the dilator. The pneumonic balloon dilators allow dilation with direct visualization. Fluoroscopy can be used as well to assist with dilation.	Schatzki Ring -- Treatment / Management. Dilation can be done with bougies or pneumonic balloons. Bougies can be used with a guidewire (Savory dilators), without a guidewire (Maloney dilators), or with a pneumonic balloon dilator. Dilation with a bougie is done without direct visualization of the esophagus, but guidewire placement is done with direct visualization during endoscopy showing the path of the dilator. The pneumonic balloon dilators allow dilation with direct visualization. Fluoroscopy can be used as well to assist with dilation.
article-28746_12	Schatzki Ring -- Treatment / Management	There has been evidence that doing four quadrant biopsies with jumbo forceps will obliterate a Schatzki ring as well. This allows direct visualization of the treatment since it is done during an endoscopy. The whole ring is not broken with biopsies; therefore, there is some concern that the residual tissue may lead to recurrence, a concern that is being studied further.	Schatzki Ring -- Treatment / Management. There has been evidence that doing four quadrant biopsies with jumbo forceps will obliterate a Schatzki ring as well. This allows direct visualization of the treatment since it is done during an endoscopy. The whole ring is not broken with biopsies; therefore, there is some concern that the residual tissue may lead to recurrence, a concern that is being studied further.
article-28746_13	Schatzki Ring -- Treatment / Management	Often patients are on some type of acid-reducing medication like a proton pump inhibitor (PPI), especially if they have mechanical obliteration of the ring with dilation or biopsy forceps. There is evidence that PPI, along with dilation, is safe and effective. The effect of PPI alone has been looked at as well in patients with average ring diameters of around 10 mm and can be followed with a barium-pill esophagram reducing the need for procedures and risks of dilation. Duration of treatment is, on average, 10 months, and the initial study only had nine participants; however, treatment is a consideration for populations of patients that are at high risk for procedures or dilations.	Schatzki Ring -- Treatment / Management. Often patients are on some type of acid-reducing medication like a proton pump inhibitor (PPI), especially if they have mechanical obliteration of the ring with dilation or biopsy forceps. There is evidence that PPI, along with dilation, is safe and effective. The effect of PPI alone has been looked at as well in patients with average ring diameters of around 10 mm and can be followed with a barium-pill esophagram reducing the need for procedures and risks of dilation. Duration of treatment is, on average, 10 months, and the initial study only had nine participants; however, treatment is a consideration for populations of patients that are at high risk for procedures or dilations.
article-28746_14	Schatzki Ring -- Differential Diagnosis	Differential diagnosis of Schatzki ring includes other causes of dysphagia, which can be extensive. Important differentials to keep in mind are eosinophilic esophagitis, reflux esophagitis, esophageal strictures other than Schatzki ring, extrinsic esophageal compression, motility disorders, and malignancy. If in combination with chest pain, then clinicians need to consider esophageal infections like candida esophagitis, pill esophagitis, radiation-induced esophagitis or stricture, or esophageal rupture, especially if the symptoms are acute.	Schatzki Ring -- Differential Diagnosis. Differential diagnosis of Schatzki ring includes other causes of dysphagia, which can be extensive. Important differentials to keep in mind are eosinophilic esophagitis, reflux esophagitis, esophageal strictures other than Schatzki ring, extrinsic esophageal compression, motility disorders, and malignancy. If in combination with chest pain, then clinicians need to consider esophageal infections like candida esophagitis, pill esophagitis, radiation-induced esophagitis or stricture, or esophageal rupture, especially if the symptoms are acute.
article-28746_15	Schatzki Ring -- Differential Diagnosis	The timing of symptoms is important if there is more progressive dysphagia of solids to eventual liquids. This is concerning for worsening obstruction, and clinicians should have a high suspicion for malignancy. With such an extensive differential, any new-onset dysphagia should be evaluated further, especially to rule out more concerning causes like malignancy.	Schatzki Ring -- Differential Diagnosis. The timing of symptoms is important if there is more progressive dysphagia of solids to eventual liquids. This is concerning for worsening obstruction, and clinicians should have a high suspicion for malignancy. With such an extensive differential, any new-onset dysphagia should be evaluated further, especially to rule out more concerning causes like malignancy.
article-28746_16	Schatzki Ring -- Prognosis	Schatzki ring is a benign stricture and, when symptomatic, can be effectively treated. The patient often does well, and symptoms improve after treatment. Recurrence does occur with rates up to 64% in the first 2 years, hence requiring repeat dilation.	Schatzki Ring -- Prognosis. Schatzki ring is a benign stricture and, when symptomatic, can be effectively treated. The patient often does well, and symptoms improve after treatment. Recurrence does occur with rates up to 64% in the first 2 years, hence requiring repeat dilation.
article-28746_17	Schatzki Ring -- Enhancing Healthcare Team Outcomes	Schatzki ring is managed by dilatation or biopsies. The condition is often managed by a gastroenterologist. However, follow-up is necessary by the nurse practitioner and primary care provider as recurrence rates are high. Most patients need repeat dilatations.	Schatzki Ring -- Enhancing Healthcare Team Outcomes. Schatzki ring is managed by dilatation or biopsies. The condition is often managed by a gastroenterologist. However, follow-up is necessary by the nurse practitioner and primary care provider as recurrence rates are high. Most patients need repeat dilatations.
article-28746_18	Schatzki Ring -- Review Questions	Access free multiple choice questions on this topic. Click here for a simplified version. Comment on this article.	Schatzki Ring -- Review Questions. Access free multiple choice questions on this topic. Click here for a simplified version. Comment on this article.
article-26212_0	Opioid Addiction (Archived) -- Introduction	Opioid use disorder and opioid addiction remain at epidemic levels in the US and worldwide. Three million US citizens and 16 million individuals worldwide have had or currently suffer from opioid use disorder (OUD). More than 500,000 in the United States are dependent on heroin. The diagnosis of OUD is made by meeting two or more of the eleven criteria in a year time period. The key elements are as follows: Increasing dose/tolerance Wish to cut down on use Excessive time spent to obtain or use the medication Strong desire to use Use interferes with obligations Continued use despite life disruption Use of opioids in physically hazardous situations Reduction or elimination of important activities due to use Continued use despite physical or psychological problems Need for increased doses of the drug Withdrawal when the dose is decreased	Opioid Addiction (Archived) -- Introduction. Opioid use disorder and opioid addiction remain at epidemic levels in the US and worldwide. Three million US citizens and 16 million individuals worldwide have had or currently suffer from opioid use disorder (OUD). More than 500,000 in the United States are dependent on heroin. The diagnosis of OUD is made by meeting two or more of the eleven criteria in a year time period. The key elements are as follows: Increasing dose/tolerance Wish to cut down on use Excessive time spent to obtain or use the medication Strong desire to use Use interferes with obligations Continued use despite life disruption Use of opioids in physically hazardous situations Reduction or elimination of important activities due to use Continued use despite physical or psychological problems Need for increased doses of the drug Withdrawal when the dose is decreased
article-26212_1	Opioid Addiction (Archived) -- Introduction	The increase in OUD can be partially attributed to overprescribing of opioid medications. Healthcare providers in the 1990s increased opioid prescribing in response to the "pain as fifth vital sign" campaign, downplay of the abuse potential of opioids, and aggressive marketing of drugs such as Oxycontin and Opana. Risk factors for misuse of these medications are initiation at a young age, previous history of illicit drug or alcohol abuse, family history of illicit drug or alcohol abuse, sexual abuse in females, adverse childhood experiences, and psychological comorbidities (depression, bipolar disorder, and attention deficit hyperactivity disorder) [1]	Opioid Addiction (Archived) -- Introduction. The increase in OUD can be partially attributed to overprescribing of opioid medications. Healthcare providers in the 1990s increased opioid prescribing in response to the "pain as fifth vital sign" campaign, downplay of the abuse potential of opioids, and aggressive marketing of drugs such as Oxycontin and Opana. Risk factors for misuse of these medications are initiation at a young age, previous history of illicit drug or alcohol abuse, family history of illicit drug or alcohol abuse, sexual abuse in females, adverse childhood experiences, and psychological comorbidities (depression, bipolar disorder, and attention deficit hyperactivity disorder) [1]
article-26212_2	Opioid Addiction (Archived) -- Etiology	Opioid addiction results from many practices and behaviors. The United States possesses an insatiable appetite for the prescription of opioid medications. In 2015, 91.8 million individuals in the United States used prescription opioids. Due to their inarguable abuse potential, these drugs are frequently misused, with high numbers of patients developing dependence. Opioid medications prescribed for mild to moderate acute pain were continued indefinitely, with no intention of tapering or ceasing use. Due to pharmacologic effects, opioids are highly addictive. Tolerance is achieved within days, and the withdrawal syndrome is severe. [2] [3] [4]	Opioid Addiction (Archived) -- Etiology. Opioid addiction results from many practices and behaviors. The United States possesses an insatiable appetite for the prescription of opioid medications. In 2015, 91.8 million individuals in the United States used prescription opioids. Due to their inarguable abuse potential, these drugs are frequently misused, with high numbers of patients developing dependence. Opioid medications prescribed for mild to moderate acute pain were continued indefinitely, with no intention of tapering or ceasing use. Due to pharmacologic effects, opioids are highly addictive. Tolerance is achieved within days, and the withdrawal syndrome is severe. [2] [3] [4]
article-26212_3	Opioid Addiction (Archived) -- Epidemiology	Opioid addiction afflicts individuals from all socioeconomic and educational backgrounds. Four million people admit to the nonmedical use of prescription opioids. Perhaps more concerning, 400,000 people had used heroin in the past month based on data from 2015 through 2016. Roughly 80% of new heroin users in the United States report pills as their initiation to opioid use and subsequent OUD. From 2002 through 2011, approximately 25 million people in the United States began nonmedical use of pain relievers. More than 11 million misused the medications. Emergency department visits due to complications and overdose have increased annually since 2010. Rates of ED visits involving opioids more than tripled from 1999 through 2013. In 2017, opioid overdose was declared a national emergency in the United States. [5] [6]	Opioid Addiction (Archived) -- Epidemiology. Opioid addiction afflicts individuals from all socioeconomic and educational backgrounds. Four million people admit to the nonmedical use of prescription opioids. Perhaps more concerning, 400,000 people had used heroin in the past month based on data from 2015 through 2016. Roughly 80% of new heroin users in the United States report pills as their initiation to opioid use and subsequent OUD. From 2002 through 2011, approximately 25 million people in the United States began nonmedical use of pain relievers. More than 11 million misused the medications. Emergency department visits due to complications and overdose have increased annually since 2010. Rates of ED visits involving opioids more than tripled from 1999 through 2013. In 2017, opioid overdose was declared a national emergency in the United States. [5] [6]