Esophageal Web

An esophageal web, described as a thin membranous extension of the esophageal mucosa and submucosa, is assumed to be present in about 10% of the population and is asymptomatic in virtually all cases [1] [2]. Its potential protrusion into the lumen of the esophagus (most commonly in the proximal portion) and compromise of food passage, however, can occur in certain disorders, such as Plummer-Vinson syndrome, where iron deficiency, the principal pathophysiological event, is assumed to promote esophageal web development [1] [3] [4] [5]. Moreover, various studies have associated esophageal webs with bullous pemphigoid, pemphigus vulgaris, epidermolysis bullosa, gastroesophageal reflux disease (GERD), glossitis, and desquamative esophagitis in graft-versus-host disease (GVHD) [2]. Regardless of the etiology, the principal symptom that could be triggered by an esophageal web is dysphagia, which may be initially painless and intermittent [2] [3]. More severe symptoms, on the other hand, include nasopharyngeal reflux, aspiration (and consequent pneumonia) and even spontaneous perforation in the setting of significant obstruction [2]. Among adults, a minor but notable predilection toward women has been observed [2] [6]. If Plummer-Vinson syndrome is the underlying cause of esophageal webs, accompanying signs are brittle hair, thinning of nails, glossodynia, angular cheilitis, and koilonychia, as well as constitutional symptoms due to anemia - fatigue, pallor, tachycardia and weakness [3] [4].

The differential diagnosis of dysphagia is rather broad, making a detailed patient history and a complete physical examination necessary to narrow the list of possible diseases. Patients should be asked about the onset and progression of symptoms, whereas additional signs may be of critical importance to suspect Plummer-Vinson syndrome or other known associated diseases in which esophageal webs are a constitutive feature. Nevertheless, the cornerstone of diagnosing esophageal webs is the implementation of one of the three imaging studies - the barium swallow test, videofluoroscopy, or upper endoscopy [4]. Barium swallow test is somewhat safer, as the web may be mechanically injured and ruptured during insertion of the endoscope, thus the diagnosis can be missed [4]. For this reason, certain authors suggest that videofluoroscopy (also known as the modified barium swallow test) is the optimal method to detect esophageal webs [2] [4]. Smooth and thin protrusions of the central lumen, often originating from the anterior wall and spreading to the lateral aspects of the esophagus, are typical findings [4]. Whenever esophageal webs are detected, a complete blood count (CBC) and further tests to confirm iron-deficiency anemia (serum iron levels, ferritin, and total iron binding capacity, or TIBC) should be performed, in order to obtain valid clinical suspicion toward Plummer-Vinson syndrome [6].

1. Tahara T, Shibata T, Okubo M, et al. A Case of Plummer-Vinson Syndrome Showing Rapid Improvement of Dysphagia and Esophageal Web after Two Weeks of Iron Therapy Case Rep Gastroenterol. 2014;8(2):211-215.
2. Liu JJ, Kahrilas PJ. Pharyngeal and esophageal diverticula, rings, and webs. GI Motility online; 2006.
3. Gude D, Bansal D, Malu A. Revisiting Plummer Vinson Syndrome. Annals of Medical and Health Sciences Research. 2013;3(1):119-121.
4. Novacek G. Plummer-Vinson syndrome. Orphanet Journal of Rare Diseases. 2006;1:36.
5. Terui K, Saito T, Mitsunaga T, Nakata M, Yoshida H. Endoscopic management for congenital esophageal stenosis: A systematic review. World J Gastrointest Endosc. 2015;7(3):183-191.
6. Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson J, Loscalzo J. eds. Harrison's Principles of Internal Medicine, 18e. New York, NY: McGraw-Hill; 2012.