esophageal web

**Definition/Anatomy:** Thin (~2-3 mm), eccentric, membrane-like mucosal fold composed of squamous epithelium and lamina propria (no muscularis propria). Most commonly located in the anterior wall of the proximal (cervical) esophagus, just below the cricopharyngeus (post-cricoid region, ~C5-C6). Can be congenital (mid/distal esophagus, often circumferential) or acquired.

**Plummer-Vinson (Paterson-Brown-Kelly) syndrome - classic triad:** 1. Dysphagia (intermittent, solids > liquids, nonprogressive) 2. Iron deficiency anemia (microcytic, hypochromic) 3. Esophageal web (upper esophagus) Associated findings: glossitis, cheilosis/angular stomatitis, koilonychia (spoon nails), atrophic changes. Classically middle-aged women (often described in white women 40-60 yrs). Pathogenesis is unclear; iron deficiency is thought to impair mucosal epithelial integrity/oxidative enzymes.

**Complications:** Increased risk of squamous cell carcinoma of the esophagus (also hypopharynx/oral cavity). Aspiration and food impaction are possible.

**Diagnosis:** Barium esophagram (best initial/most sensitive, especially with lateral views and videofluoroscopy) shows a thin, anterior, shelf-like filling defect in the cervical esophagus. Endoscopy can miss webs (may rupture the web on passage) but is used to exclude carcinoma and other causes. Labs: CBC, ferritin, iron studies.

**Treatment:** - Iron supplementation (often improves symptoms and can reverse the web) - Endoscopic dilation (bougie/balloon), which disrupts the web, for persistent symptoms - Surveillance given cancer risk

**Differential for dysphagia (high-yield contrasts):** - Schatzki ring: lower esophageal mucosal ring at the squamocolumnar junction; intermittent solid dysphagia, often with a hiatal hernia ("steakhouse syndrome") - Zenker diverticulum: false (pulsion) diverticulum through Killian triangle; dysphagia, halitosis, regurgitation of undigested food, gurgling neck mass - Esophageal carcinoma: progressive dysphagia (solids then liquids), weight loss - Achalasia: both solids and liquids from the start, bird-beak sign - Eosinophilic esophagitis: rings ("trachealization"), atopy, food impaction - Peptic stricture: history of GERD

**Board pearl:** A middle-aged woman with intermittent solid-food dysphagia, microcytic anemia, and glossitis, with an upper esophageal web on barium swallow, has Plummer-Vinson syndrome. Treat with iron and dilation, and remember the SCC risk.