What is the relationship between anemia, specifically iron-deficiency anemia, and the development of esophageal webs?

The Relationship Between Iron Deficiency Anemia and Esophageal Webs

Iron deficiency anemia causes esophageal webs through a condition known as Plummer-Vinson syndrome (PVS), which is characterized by the triad of iron deficiency anemia, dysphagia, and post-cricoid esophageal web formation. 1

Pathophysiology of Esophageal Web Formation in Iron Deficiency

• Iron deficiency leads to epithelial changes in the mucosa of the upper digestive tract, resulting in web formation in the post-cricoid region of the esophagus 2, 1
• The exact mechanism remains unclear, but the rapid improvement of webs with iron therapy suggests a direct relationship between iron deficiency and mucosal changes 3
• Chronic iron deficiency appears to cause atrophy of the mucosa and reduced repair capacity of the epithelium, leading to web formation 1

Clinical Presentation of Plummer-Vinson Syndrome

• PVS predominantly affects middle-aged women (85.6% of cases in a large study) 1
• Key clinical features include:
  • Dysphagia (difficulty swallowing) 2, 1
  • Iron deficiency anemia with typical signs (pallor, koilonychia, angular cheilitis, glossitis) 3
  • Post-cricoid esophageal web visible on endoscopy or barium swallow 2
• Additional symptoms may include:
  • Occasional choking and aspiration episodes during eating 2
  • Weight loss 3
  • Shortness of breath due to anemia 3

Diagnostic Approach

• Laboratory findings typically show microcytic hypochromic anemia with confirmed iron deficiency 3
• Endoscopy may reveal difficulty passing the scope through the upper esophagus due to web presence 2
• Barium-swallow esophagography can detect webs in the post-cricoid region 3
• Serum ferritin below 30 μg/L (without inflammation) or up to 100 μg/L (with inflammation) confirms iron deficiency 4

Treatment and Response

• Iron supplementation is the primary treatment and can lead to dramatic improvement:
  • Some cases show rapid resolution of dysphagia and web reduction after just 2 weeks of oral iron therapy 3
  • Correction of iron deficiency may result in complete resolution of dysphagia and sometimes disappearance of the webs 2
• Mechanical dilation is often required in addition to iron therapy:
  • Savary-Gilliard bougie dilation or balloon dilation is effective in 90.7% of cases with a single session 1
  • About 9.3% of patients may develop recurrence requiring repeated dilations 1

Long-term Complications and Monitoring

• PVS is associated with an increased risk of malignancy:
  • 4.5% overall risk of developing upper gastrointestinal malignancy 1
  • Squamous cell carcinoma of the hypopharynx, oral cavity, or esophagus occurs in approximately 10% of patients 5
  • Gastric cancer has also been reported in rare cases 5
• Regular follow-up is essential for early detection of recurrent iron deficiency or malignancy 6

Prevention of Recurrence

• Monitoring for recurrent iron deficiency is recommended:
  • Every 3 months for at least a year after correction 4
  • Periodically thereafter 4
• Maintaining normal hemoglobin and serum ferritin levels is the goal of preventive treatment 4
• Recurrent anemia may indicate persistent underlying disease even with normal inflammatory markers 4

Iron deficiency anemia causing esophageal webs (Plummer-Vinson syndrome) represents an important clinical entity that responds well to treatment but requires vigilance due to its association with upper gastrointestinal malignancies.