How is Plummer-Vinson syndrome managed?

Management of Plummer-Vinson Syndrome

Plummer-Vinson syndrome should be managed with oral iron supplementation as first-line therapy, combined with esophageal dilation when dysphagia persists or is severe. 1, 2, 3

Immediate Diagnostic Confirmation

• Confirm the classic triad: iron deficiency anemia (microcytic hypochromic), dysphagia (typically painless and limited to solids), and post-cricoid esophageal web on endoscopy or barium swallow 1, 3, 4
• Look for additional clinical features including glossitis, angular cheilitis, koilonychia, conjunctival pallor, and smooth tongue 1, 2, 4
• Perform upper endoscopy to visualize the web directly and assess for any concurrent malignancy, as PVS carries a 4.5% risk of upper gastrointestinal malignancy 3, 4

Primary Treatment: Iron Supplementation

Begin oral iron supplementation immediately upon diagnosis, as this alone can resolve dysphagia and cause esophageal webs to disappear in some patients. 1, 2, 4

• Iron therapy can produce dramatic improvement in dysphagia within as little as 2 weeks, with documented improvement of luminal stenosis on repeat endoscopy 2
• Continue iron supplementation until hemoglobin normalizes and iron stores are replenished 1, 2
• Monitor hemoglobin levels during treatment to assess response 2

Esophageal Dilation: When and How

Proceed with mechanical dilation when dysphagia persists despite iron supplementation or when the web causes significant obstruction preventing endoscope passage. 1, 3, 4

• Use Savary-Gilliard bougie dilation as the preferred method, which achieves successful relief of dysphagia in 90.7% of patients with a single session 3
• Balloon dilation is an alternative effective technique 1
• Approximately 9.3% of patients develop recurrent dysphagia requiring repeated dilations 3
• Dilation is particularly necessary when the endoscope cannot pass through the upper esophagus at initial evaluation 1

Treatment Algorithm

1. Start oral iron supplementation immediately in all patients with confirmed PVS 1, 2, 4
2. Reassess at 2 weeks: If dysphagia improves significantly, continue iron therapy alone 2
3. If dysphagia persists or worsens at 2 weeks, or if initial presentation involves complete obstruction or aspiration episodes, proceed with esophageal dilation 1, 3
4. Perform single-session Savary-Gilliard bougie dilation combined with continued iron supplementation 3

Critical Long-Term Surveillance

All patients with PVS require lifelong surveillance for upper gastrointestinal malignancy, particularly squamous cell carcinoma of the pharynx and esophagus. 3, 4

• The overall risk of developing upper gastrointestinal malignancy is 4.5%, with some patients presenting with concomitant squamous cell carcinoma at diagnosis 3
• Schedule regular endoscopic surveillance, though specific intervals are not definitively established in the literature 4
• Monitor for recurrence of dysphagia, which occurs in approximately 9.3% of patients after initial successful dilation 3

Common Pitfalls to Avoid

• Do not delay iron supplementation while waiting for dilation procedures, as iron therapy alone may resolve symptoms and avoid the need for intervention 2, 4
• Do not assume dysphagia resolution with iron therapy alone means cure—patients still require malignancy surveillance regardless of symptom improvement 3, 4
• Do not overlook PVS in elderly patients: while classically described in middle-aged women (fourth to seventh decade), it can occur in octogenarians and should not be dismissed based on age alone 5, 4
• Do not perform dilation without concurrent iron supplementation, as addressing the underlying iron deficiency is essential for preventing recurrence 1, 4