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Iron deficiency anemia and Plummer–Vinson

syndrome: current insights

This article was published in the following Dove Press journal:

Journal of Blood Medicine
19 October 2017
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Amit Goel 1 Abstract: Plummer–Vinson syndrome (PVS), a rare clinical condition, is characterized by a
Satvinder Singh Bakshi 2 triad of dysphagia, iron deficiency anemia and esophageal web in the post-cricoid region. It
Neetu Soni 3 was first described over a century ago. However, literature on this condition remains scanty, and
Nanda Chhavi 4 its prevalence appears to be declining worldwide, possibly due to improvements in nutrition
over time. The condition has been reported most commonly in thin-built, middle-aged, white
1
Department of Gastroenterology,
Sanjay Gandhi Postgraduate Institute women. The esophageal webs in PVS are thin mucosal folds, which are best seen either in lat-
of Medical Sciences, Lucknow, India; eral views at barium swallow or at esophagoscopy. These are usually semilunar or crescentic,
2
Department of Otorhinolaryngology being located most often along the anterior esophageal wall, but can be concentric. The exact
and Head and Neck Surgery,
Mahatma Gandhi Medical College cause and pathogenesis of PVS remain unclear, though iron and other nutritional deficiencies,
and Research Institute, Puducherry, genetic predisposition and autoimmunity have all been implicated in formation of the webs.
India; 3Department of Radiodiagnosis,
Treatment includes correction of iron deficiency and endoscopic dilation of the esophageal
Sanjay Gandhi Postgraduate Institute
of Medical Sciences, Lucknow, India; webs to relieve dysphagia. PVS is associated with an increased risk of hypopharyngeal and
4
Department of Pediatrics, Era’s esophageal malignancies. Correction of iron deficiency may arrest and reverse the mucosal
Lucknow Medical College, Lucknow,
India
changes and possibly reduces this risk.
Keywords: Plummer –Vinson syndrome, Paterson–Brown–Kelly syndrome, esophageal web,
dysphagia, iron deficiency anemia

Introduction
Difficulty in swallowing or dysphagia is a common symptom. Esophageal webs are an
infrequent cause of dysphagia. These have been found to occur in association with iron
deficiency anemia (IDA) and dysphagia. This clinical triad – of IDA, esophageal web
and dysphagia – has been named variously as “Plummer–Vinson syndrome” (PVS;
primarily in the USA) and as “Paterson–Brown–Kelly syndrome” (used primarily in
the UK).1 The former term was derived from the names of two physicians – Henry
Stanley Plummer and Porter Paisley Vinson, at the Mayo Clinic – who separately
described this condition and speculated that “cardiospasm”2 and “angulation”3 of the
esophagus, respectively, were responsible for the dysphagia. Around the same time,
two laryngologists from Britain, Donald Ross Paterson and Adam Brown-Kelly, pro-
vided detailed clinical descriptions of this condition and also noticed its association
with anemia and post-cricoid webs,4,5 helping establish this entity as an independent
Correspondence: Amit Goel syndrome, a contribution recognized by the name “Paterson–Brown–Kelly syndrome”.
Department of Gastroenterology, Sanjay
Gandhi Postgraduate Institute of Medical This review uses the term PVS throughout because of its somewhat more frequent use
Sciences (SGPGI), Rae Bareli Road, in the recent published literature.
Lucknow 226014, India
Tel +91 522 249 5549
PVS is a rare condition that continues to be enigmatic, even though a century has
Email agoel.ag@gmail.com passed since its first description.2 The literature available on its pathogenesis, treatment

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and natural history is limited to case reports, retrospective malnutrition, genetic predisposition, autoimmune processes
short case series and a few large series.6,7 In this review, we and other dietary deficiencies (such as of pyridoxine or
have attempted to collate the available information on PVS. riboflavin).

Epidemiology Iron deficiency anemia

It is interesting to note that, after passage of a century since IDA is the most extensively studied and currently the most
its first description, literature on PVS is still restricted to case widely accepted causative association of PVS. The assumed
reports and small case series.8–10 PVS has been reported from role of IDA in the formation of esophageal webs is based
all parts of the world. In the initial decades after its descrip- primarily on: 1) its common association with such webs in
tion, several reports of PVS emerged from Europe11–14 and patients with PVS, 2) a high prevalence of IDA in patients
North America,15–17 reflecting its increasing recognition in the with post-cricoid dysphagia, 3) reports of improvement
areas from where it was first described. However, with eco- in dysphagia and disappearance of esophageal web25 and
nomic growth and improvement in nutrition in these regions, associated esophageal motility disturbances following iron
the condition appears to have disappeared there. Instead, in therapy,26,27 and 4) the presence of risk factors for IDA, such
the last few decades, PVS has been increasingly recognized as post-gastrectomy status, atrophic gastritis, achlorhydria
in developing countries of Asia, with most of the reports com- and female gender, in patients with esophageal webs.28
ing from this continent.8,18–21 The sharp decline in reports on However, the IDA hypothesis fails to explain several
PVS from the developed world has temporally coincided with observations, namely, the occurrence of webs in some patients
the disappearance of iron deficiency, because of combined in the absence of IDA,29 lack of concordance between the
effects of improved nutritional status and hygiene, reduced geographic distribution of IDA and esophageal webs, rarity
worm infestation, iron supplementation and fortification of of web formation despite a high prevalence of IDA in African
dietary substances with iron.22 Interestingly, despite a high populations, poor association of severity of IDA with the
prevalence of IDA in Africa, PVS has rarely been reported severity of dysphagia, the exclusive post-cricoid location
there, though this may reflect the low contribution of this of esophagus webs in patients with IDA, and the failure to
continent to the published medical literature.10,20,23 induce similar lesions in animal models with iron deficiency.30
PVS is a rare condition, and the data on its incidence or Thus, though the current knowledge suggests a central
prevalence rate are limited to a single population-based study role for IDA in predisposing the post-cricoid mucosa to web
conducted in South Wales in early 1960s.14 In this study, formation, it does not appear to be adequate by itself and
1994 men and 2346 women were screened for post-cricoid appears to require the presence of some additional factors.
dysphagia using a questionnaire followed by a barium study Further information on the role of iron in the formation of
in those reporting symptoms. The prevalence of post-cricoid post-cricoid webs is available in an excellent review on the
webs was found to be 0.3%–1.1% and 8.4%–22.4% among subject, albeit published several years ago.30
women overall and in women with dysphagia, respectively.
None of the men were found to have a post-cricoid web.14 Other nutritional deficiencies
In a large radiologic study from New York, 1000 con- Deficiencies of some B vitamins, such as riboflavin, thiamine
secutive cineradiographs of the hypopharynx and cervical and pyridoxine, have been proposed as a cause for PVS,
esophagus were examined, and esophagus webs were found though the evidence for this is weak and inconclusive. Muco-
in 5.5% of these. However, of the 55 patients with webs, only sal changes in the oropharynx, such as stomatitis, atrophy of
6 had dysphagia attributable to these webs, and none met the the lingual epithelium, loss of lingual papillae and angular
criteria for PVS.24 cheilosis, have been described in persons with riboflavin and
pyridoxine deficiencies, and can be induced experimentally in
Etiology animal models. Frequent occurrence of dysphagia, hypopha-
The exact cause for PVS and of web formation remains ryngeal and oral cancers has been described among women
unknown. Several hypotheses have been proposed to explain from remote rural areas in northern Sweden, where vitamin
their pathogenesis, each supported by relatively weak evi- deficiencies were common, because of long winter seasons
dence, consisting primarily of the clinical associations of and consequent poor supply of fresh vegetables, meat and
esophageal webs and PVS with other systemic illnesses. fish.31 Riboflavin also plays a key role in several steps during
The proposed causative mechanisms have included IDA, erythropoiesis, including iron absorption and m ­ obilization

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Dovepress Dysphagia and iron deficiency anemia

of ferritin from tissues, and its deficiency could thus con- turnover, rather than in rapidly renewing mucosa located in
tribute to anemia.32 However, Jacobs and Cavill reported the small or large intestine.
that riboflavin content of the red blood cells was normal in IDA is associated with degeneration and atrophy of the
25 PVS patients, and was comparable between anemic and epithelial lining of the tongue, hypopharynx and stomach,
non-anemic patients.33 though there is no correlation between the severity of these
epithelial changes and the severity and duration of IDA.
Autoimmunity Detailed histologic examination reveals epithelial atrophy,
Host’s immune response against a self-antigen, which is yet often with subepithelial round cell infiltration, parakeratosis
unrecognized, has also been proposed as playing a role in or abnormal keratinization, and reduced levels of glycogen
the formation of esophageal web. This hypothesis is based and cytochrome oxidase in the prickle cells.
on reports highlighting the association of PVS with autoim- The unhealthy mucosa in the hypopharynx elicits a
mune disease.28,34,35 Celiac disease, an autoimmune condition, chronic, low-grade inflammation leading to submucosal
can present as refractory IDA and can be considered as an fibrosis which may extend into the surrounding pharyngeal
etiologic factor in PVS.20,36–38 Abnormally high prevalence muscles. These mucosal changes probably occur throughout
of overt and latent pernicious anemia is reported in patients the esophagus, but manifest in only the post-cricoid region
with IDA.39,40 In addition, cases of PVS with thyroiditis, which faces the maximal trauma during swallowing of solid
rheumatoid arthritis41 or Crohn’s disease18 have also been bolus. The risk for trauma in this region is further increased
reported. Furthermore, there is evidence to support an auto- because it is bound, both anteriorly and posteriorly, by skel-
immune mechanism for mucosal changes of atrophic gastritis etal elements. As the cricoid cartilage moves upward during
in patients with iron deficiency.42 swallowing, the mucosa on its posterior aspect is drawn
over the descending food bolus, leading to trauma and web
Pathogenesis formation.46
The exact pathogenesis of PVS or formation of esophageal An alternative explanation for the specific location of the
web is unclear, partly because such studies are difficult to web is the possible existence in some people of a band of
conduct due to the infrequent nature of this condition. Several ectopic gastric mucosa in the upper esophagus, acid secre-
hypotheses have been put forward to explain the pathogenesis tion from which causes local inflammation and stricture
of web formation and its peculiar location,43 though IDA is (web) formation. However, this hypothesis fails to explain
the only factor that is unanimously accepted to play a role. the nonexistence of webs in the lower esophagus, which is
Iron is an important element for normal body homeosta- more frequently and more intensely exposed to gastric acid.16
sis. It is essential for hemoglobin and myoglobin synthesis Furthermore, the inflammatory origin of the web fails to
and also acts as a cofactor for several enzymes involved explain the thin, film-like nature of the web.
in cellular metabolism. The origin of esophageal web is Abnormal movement of muscles in pharynx and esopha-
proposed to be related to a reduction in the activity of iron- gus has also been implicated in web formation. Anemia
dependent oxidative enzymes, secondary to iron deficiency. may cause decreased esophageal motility, possibly through
This results in gradual degradation of the pharyngeal muscles impaired mitochondrial function and/or low neuronal nitric
and atrophy of the mucosa overlying them, leading to the oxide synthetase activity. Impaired heme synthesis, seen in
development of webs.44 This hypothesis is supported by IDA, may induce mitochondrial DNA damage and cause a
evidence from a histochemical study of thyropharyngeal, functional defect in these organelles by a poorly understood
cricopharyngeal and cervical esophageal muscles from mechanism. Mitochondrial impairment has been linked to
rabbits with IDA, which showed mitochondrial damage, cancer, aging and most neurodegenerative diseases such as
with a “moth eaten” appearance, in type I muscle fibers. web formation.
These changes were similar to those observed in muscles of A detailed radiographic swallowing study of PVS has
patients with progressive muscular dystrophy.45 These losses shown that the anterior wall of the upper esophagus in these
of iron-dependent enzymes are further aggravated because patients fails to dilate following liquid bolus, thereby forming
of the high turnover of gastrointestinal tract epithelial lining. a fold, which gives the impression of a web on esophagogra-
However, this theory fails to explain the localization of webs phy.45 Another study showed reduced esophageal motility in
exclusively in the upper esophagus, which is lined with a patients with IDA without esophageal web, which improved
stratified squamous epithelium which has a relatively slower with iron supplementation.27 In a prospective comparison

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Goel et al Dovepress

of oropharyngeal and esophageal transit and esophageal presenting features, and some patients do not have a clearly
motility between IDA patients and healthy volunteers, the demonstrable web. Similarly, all the patients with IDA and
former group showed a slower esophageal transit, with shorter esophageal web do not have dysphagia.
duration and lower amplitude of esophageal contractions, The dysphagia in PVS has a gradual onset, and is usually
particularly in the upper and middle esophagus, that is, the painless and intermittent. Patients usually point to the neck
location of the web.47 at or above the suprasternal notch as the site of obstruction.
Overall, it appears that several factors such as iron defi- Dysphagia is usually noticed first for solid foods, which is
ciency, mucosal inflammation and atrophy, muscle degenera- then followed after several years by difficulty in swallowing
tion, food bolus–induced trauma and esophageal dysmotility liquids, suggesting an extremely slow progression of the
contribute to the web formation in PVS, though the absolute esophageal obstruction. The patients tend to circumvent the
and relative contribution of each factor remains elusive. symptom by either modifying the diet or consuming softer
solids, and/or by enhanced chewing to break the food into
Morphology of esophageal webs smaller particles. Thus, there is often an interval of several
Esophageal webs are thin, shelf-like, circular or semi-circular, years between the onset of dysphagia and the patient seeking
pink-whitish, membranous structures consisting of two lay- medical attention.53 The obstruction may result in the person
ers of mucosa and scanty fibrous tissue sandwiched between taking longer to complete a meal. With worsening obstruc-
them, but without any muscular tissue. These are located tion, choking and/or episodes of aspiration may occur.
exclusively in the upper esophagus, usually just below the Dysphagia manifests only when the luminal diameter in
upper esophageal sphincter. This location makes it difficult the region of the web becomes <12 mm. Two recent reports of
to obtain a biopsy of a web. PVS, which graded severity of dysphagia using this system,
In the limited histologic data available, the webs in showed that nearly 80% of the symptomatic patients with
patients with PVS are characterized by fibrosis, epithelial PVS had grade I (occasional dysphagia on taking solid foods)
atrophy, epithelial hyperplasia and hyperkeratosis, basal cell or II (able to swallow only semi-solid diet) dysphagia;6,55
hyperplasia and irregularities, combined occasionally with more severe grades of dysphagia (grade III: able to swallow
features of chronic inflammation. Overall, the histologic only liquid diet, or grade IV: inability to take even liquids in
appearance is that of a fold of normal esophageal epithelium adequate amount) were infrequent.54
with some underlying loose connective tissue.48 In a few Anemia can manifest with several symptoms, such as
patients, precancerous epithelial changes have also been easy fatigability, exertional dyspnea, weakness, palpitations
noted. Subepithelium shows infiltration with round cells. and so on, and any one or a combination of these symptoms
Similar histologic changes have been described in buccal may bring the patient to the physician. Physical examination
mucosa in patients with IDA.49 reveals pallor.
IDA may be associated with deficiencies of other nutri-
Clinical features ents, in particular, vitamins, which could manifest as sore-
In large clinical series and a population-based study, the major- ness of mouth, glossitis, angular cheilitis, atrophic glossitis
ity of patients were middle aged.6,14,50 PVS has also rarely been (­Figure 1), premature loss of teeth, koilonychia (spoon-
reported in children and adolescents.12,13,51 The average age of shaped finger nails), clubbing, seborrheic dermatitis, hyper-
patients with post-cricoid carcinoma is about 15 years older than keratosis, conjunctivitis, keratitis, blepharitis, paresthesia
that of patients with PVS.52 Whites appear to be affected more and/or night blindness. Occasionally, women may experience
often than the black population groups. Women are affected complaints of burning and itching in the vulval region, which
much more often than men, such that, at one point of time, disappears after iron treatment, suggesting involvement of
PVS was considered to be a disease exclusively of women. genital mucosa with epithelial lesions similar to those in the
Two large studies have shown female-to-male ratio of ~8.5:1.6,7 mouth and throat.
This striking female preponderance may be attributable at least Occasionally, PVS may be associated with other con-
partly to a higher prevalence of IDA among women, because ditions, such as an autoimmune disease, celiac disease,
of lower dietary intake, menstrual blood loss and pregnancy. malignancy and so on. In such cases, the symptoms of
The typical triad of PVS is not seen in all patients with these associated conditions may predominate over the long-
esophageal web. Dysphagia and IDA are the most common standing mild dysphagia or well-tolerated anemia.

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Dovepress Dysphagia and iron deficiency anemia

likely, investigations to look for the presence and cause of

blood loss from the gastrointestinal tract are needed.

Radiography of the esophagus

Barium swallow radiography is the investigation most com-
monly asked for if an esophageal web is suspected. It has a
few advantages over endoscopic examination. Besides being
time-honored, it is more easily available in remote locations
and can be interpreted by a radiologist or a clinician with
no special skill or training. Further, it helps to differentiate
between benign and malignant causes of obstruction, plan-
ning of definitive treatment, and provides a reproducible
documentation of pretreatment status for comparison after
Figure 1 Picture showing glossitis and angular cheilosis.
treatment or other later use.56
Occasionally, the information provided by conventional
Laboratory investigations barium swallow is either equivocal or negative and not com-
The objectives of investigations in a patient with suspected mensurate with clinical suspicion. Such patients need video
esophageal web or PVS are: to diagnose anemia, ascertain cineradiography and/or video fluoroscopy, which provide a
the cause of anemia, assess the severity and cause of dys- dynamic X-ray evaluation of the process of swallowing, as
phagia and to localize the obstructing lesion to help plan the barium bolus moves from the mouth to the esophagus.57
definitive treatment. Hence, the investigations include These techniques can identify smaller webs and can better
hematologic tests, and radiographic (barium swallow) distinguish true webs from false webs formed by mucosal
and endoscopic examinations of the esophagus. In some folds or extrinsic pressure. However, these are not easily
patients, further investigations may be required to identify available, particularly in developing countries where PVS
associated conditions such as thyroid disorders, celiac is common.
disease and so on to exclude hypopharyngeal or esopha- To obtain the maximum information from barium swal-
geal malignancy and to identify the cause for IDA, such low or cineradiography, a few precautions are in order.
as looking for occult blood loss, endoscopic examination These include the use of a large bolus of thick barium and
to look for lesions in the distal gastrointestinal tract and acquisition of lateral view images in standing position. In
investigations to look for the cause of blood loss from the these images, a web would appear as a thin projection in
female genital tract and so on. the post-cricoid region or in the upper esophagus, with a
dilated proximal segment and a normal or relatively narrowed
Hematologic tests distal segment.58–60 The webs are most commonly located on
Hemoglobin concentration in blood, microscopic examina- the anterior wall of the esophagus (Figure 2A), but can be
tion of peripheral blood smear, red cell indices (mean cor- located occasionally on the posterior wall (Figure 2B). Less
puscular volume, mean corpuscular hemoglobin and mean frequently, they are circumferential (Figure 2C), with either
corpuscular hemoglobin concentration) and serum iron a centrally placed or eccentrically placed opening. Though
studies (serum iron, ferritin and total iron binding capacity) usually solitary, webs can also be multiple.6
are helpful in diagnosing the presence or absence of anemia Webs need to be differentiated from other benign or
and to establish iron deficiency as its cause. According to malignant causes of pharyngeal dysphagia,56 such as pharyn-
the World Health Organization, a hemoglobin level of <12 geal pouches or diverticula, Zenker’s diverticula, idiopathic
g/dL in nonpregnant women or <13 g/dL in men is used to esophageal stricture, benign or malignant tumors or extrin-
define anemia. Iron deficiency is considered as the cause for sic compression of esophagus. Esophageal strictures can
anemia in the presence of microcytic hypochromic picture be distinguished from webs by demonstration of restricted
on peripheral blood smear examination, serum ferritin level distensibility of the neighboring esophageal wall, secondary
<30 μg/L and mean corpuscular volume <80 fL. IDA can be to inflammation and fibrosis.
caused either by poor intake of iron or excessive loss of body Forceful propulsion of barium through a relatively nar-
iron. If poor intake or genital blood loss is not considered row opening of the web often produces a “jet phenomenon”.

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A B

Figure 2 Lateral view of barium swallow study showing esophageal web on (A) anterior wall, (B) posterior wall, and (C) a circumferential web.

Width of the jet immediately below the level of the web

indicates the degree of narrowing (Figure 3). Sometimes,
the web cannot be seen and its possibility is considered only
because the jet phenomenon is observed; though infrequent,
presence of this sign is fairly diagnostic of a web.61 Its pres-
ence suggests a critical narrowing, and hence, patients with
it are more likely to be symptomatic. In a recent prospective
study, 86% of the esophageal webs were diagnosed by barium
swallow and most of these webs showed jet phenomenon and
poor lumen distensibility below the web.6

Video endoscopy
Fiber-optic endoscopy is a safe and reliable tool for exam-
ining gastrointestinal tract. Endoscopic examination of the
Figure 3 Lateral view of barium swallow study in a patient with circumferential web
esophagus is called esophagoscopy. Esophagoscopy has the with severe narrowing producing “jet phenomenon” below the level of narrowing
advantage of permitting treatment in the same sitting. In because of the web.

patients suspected to have an esophageal web, endoscopic

examination has to be performed very cautiously, preferably often not evaluated well during esophagoscopy (Figure 4A,
under anesthesia or sedation. These webs are very thin and are B). Hence, if the endoscopist is not aware or informed of the
located very close to the upper esophageal sphincter in the esophageal web, he/she may rupture it during the passage
esophagus, an area which is traversed very fast and, hence, is of the endoscope. Such an unintended rupture of a web will

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Dovepress Dysphagia and iron deficiency anemia

Figure 4 Endoscopic view of upper esophagus showing webs: (A) semilunar or crescent, and (B) circumferential.

produce a small amount of bleeding at the site of esophageal retained foreign bodies in the pharynx or esophagus should
web, which could be misinterpreted, by the endoscopist, as be considered, particularly in those at the extreme of ages.
mucosal irregularity due to esophageal carcinoma. Confus-
ing a benign pathology with a malignant one will result in a Treatment
trail of unnecessary investigations and follow-up, leading to Patients with PVS need treatment for IDA as well as for
unnecessary financial burden and psychologic stress. dysphagia.
At endoscopy, the webs appear as smooth, thin, gray
lesions with eccentric or central lumen and normal-appearing Iron deficiency anemia
mucosa. Careful examination of the remaining esophagus An important first step in the management of IDA is to exclude
and the stomach is essential to exclude the presence of a occult or overt blood loss from any source, such as menstrual
malignancy, since PVS has been considered as a precancer- bleeding, gastrointestinal tract malignancy, worm infestation
ous condition. Furthermore, the examination of stomach and and so on, or iron malabsorption, for example, celiac disease.
duodenum may identify a cause for IDA. In the majority of patients with PVS, the iron deficiency is
nutritional and can be treated easily with iron supplementa-
Differential diagnosis tion, either oral or parenteral. Several recent excellent reviews
It is important to distinguish PVS from other causes of are available on iron therapy62–64 and may be consulted.
dysphagia. It must be remembered that causes of dysphagia Iron supplementation alone resolves dysphagia in many
other than PVS are much more common, and hence, mere patients.65,66 This treatment alone could be considered for
presence of IDA or a web should not lead to the diagno- those with mild dysphagia or if endoscopy facilities are not
sis of PVS. The benign causes which need consideration available. Advanced and long-standing dysphagia is unlikely
include vascular rings, pharyngeal pouch and diverticulum, to respond to iron replacement alone and requires dilatation
esophageal strictures secondary to corrosive injury, surgical of the web. Iron therapy should be considered in all patients
anastomosis in the esophagus specifically following surgery with web, regardless of the hemoglobin status, to replenish
for tracheoesophageal fistula in the neonatal period, esopha- the iron stores.
geal strictures following esophageal injury (blunt trauma,
penetrating injuries), compression effects, gastroesophageal Post-cricoid web
reflux disease and idiopathic stricture. Esophageal motility Esophageal webs have been dilated using various endoscopic
disorders such as scleroderma, achalasia cardia, diffuse techniques, with the largest experience being with the use of
esophageal spasm and nutcracker esophagus can also present endoscopic balloon dilatation6 or Savary-Gilliard dilators.7,67
with dysphagia, and the web may be an incidental finding. In Endoscopic laser division and electroincision have also been
addition, benign and malignant tumors of the esophagus and used successfully.19,68 Surgery is only rarely needed.

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Both endoscopic balloon and Savary-Gilliard dilators are p­ erformed under fluoroscopic guidance after passing a guide-
used after anesthetizing the throat mucosa with xylocaine spray wire into the stomach at endoscopy. Successful rupture of the
or syrup. Light sedation helps improve patient comfort and does web is recognized at endoscopy by the presence of a small
not appear to increase the risk of complication. D ­ ilatation is amount of fresh blood at the location of the web (Figure 5A, B).

Figure 5 Endoscopic view of upper esophagus showing (A) balloon dilatation of web, and (B) fresh blood and remnants of circumferential web in the form of a rim after
successful balloon dilatation.

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Dovepress Dysphagia and iron deficiency anemia

In a prospective study, a single session of balloon dilata- Disclosure

tion provided complete response in 94% of patients, with The authors report no conflicts of interest in this work.
only some patients needing a repeat session.6 The recurrence
of dysphagia is very uncommon. The rate of recurrence of References
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