Oesophageal Web

A thin (usually less than 2 mm), eccentric or circumferential shelf of squamous mucosa and submucosa that projects into the oesophageal lumen, most often in the cervical oesophagus just below the cricopharyngeus on the anterior wall.

• Found in about 5 to 15% of patients having a barium swallow for dysphagia, though most webs are asymptomatic; female predominance and middle age.
• Causes: Plummer-Vinson (Paterson-Brown-Kelly) syndrome (iron deficiency anaemia, dysphagia and a web; women aged 40 to 60 years), gastro-oesophageal reflux, eosinophilic oesophagitis, graft-versus-host disease, mucous membrane pemphigoid, pemphigus vulgaris, epidermolysis bullosa, lichen planus, congenital (idiopathic) webs, and rarely caustic or radiation injury.
• Mechanism in iron deficiency: epithelial atrophy and abnormal repair; the web then interferes with passage of solid food.
• Risk of hypopharyngeal and oesophageal squamous cell carcinoma in Plummer-Vinson syndrome is raised (about 3 to 15%), so this deserves follow-up.

Intermittent dysphagia for solid foods (often bread or meat) localised to the neck or upper chest, which is non-progressive; patients learn to chew well and use liquids.

• Regurgitation, coughing or aspiration, globus sensation, weight loss rarely.
• Iron deficiency features: pallor, fatigue, glossitis, angular cheilitis, koilonychia (spoon nails), dry skin, brittle hair, splenomegaly (in Plummer-Vinson).
• Differential diagnosis: cricopharyngeal bar or hypertrophy, Zenker diverticulum, oesophageal ring, peptic stricture, eosinophilic oesophagitis, hypopharyngeal or oesophageal cancer, achalasia, thyroid enlargement, post-cricoid carcinoma.
• Complications: food impaction, aspiration, nutritional compromise, and squamous cell carcinoma in Plummer-Vinson syndrome.

Videofluoroscopy or a barium swallow with lateral views is the best test for a cervical web: a thin anterior shelf-like filling defect in the postcricoid region, often missed on the frontal view.

• Upper endoscopy to examine the hypopharynx and oesophagus; a web may be missed or ruptured by the endoscope, so tell the endoscopist; biopsy any abnormal mucosa and take oesophageal biopsies for eosinophilic oesophagitis and lichen planus.
• Blood tests: full blood count (microcytic hypochromic anaemia), ferritin (less than 30 micrograms/L indicates iron deficiency), iron and transferrin saturation, vitamin B12 and folate, thyroid function.
• Look for the cause of iron deficiency: coeliac serology (tissue transglutaminase IgA), H. pylori, gastrointestinal blood loss, menstrual loss, diet.
• Direct laryngoscopy and examination of the hypopharynx in Plummer-Vinson syndrome.

Treat iron deficiency, dilate the web if symptoms persist, and treat any associated cause.

• Iron replacement: ferrous sulfate 200 mg (65 mg elemental iron) once daily or on alternate days for 3 to 6 months after haemoglobin normalises (take with vitamin C 500 mg, and apart from tea, coffee and acid suppressants); ferric carboxymaltose 1000 mg IV once (maximum 20 mg/kg) when oral iron is not tolerated or fails; many webs improve or resolve with iron alone.
• Dilatation for persistent dysphagia: bougie (Savary) or balloon dilatation to 15 to 18 mm in one or two sessions; relief in over 90%; recurrence in about 10 to 20%, which may need repeat dilatation.
• Endoscopic disruption: rupture of a thin web with the endoscope, biopsy forceps or cautery (radial incision) when dilatation fails; surgery is rarely required.
• Reflux: omeprazole 20 to 40 mg daily for 8 weeks and lifestyle measures.
• Eosinophilic oesophagitis: omeprazole 20 to 40 mg twice daily for 8 weeks, fluticasone propionate 880 micrograms twice daily swallowed, or budesonide orodispersible tablet 1 mg twice daily for 8 to 12 weeks.
• Immune-mediated disease (pemphigoid, pemphigus, lichen planus, graft-versus-host disease): specialist treatment with topical or systemic corticosteroid (prednisolone 0.5 to 1 mg/kg daily) and dilatation with caution.
• Diet and lifestyle: soft food, chew carefully, small bites, stop smoking and reduce alcohol, which raise cancer risk.
• Plummer-Vinson syndrome surveillance: examination of the hypopharynx and endoscopy at diagnosis and periodically (every 1 to 3 years; evidence is limited) and review of any new or progressive dysphagia, weight loss or odynophagia.
• Special groups: children (congenital webs: dilatation under anaesthesia; iron deficiency screen); pregnancy (oral iron 65 mg elemental daily or alternate days, IV iron after the first trimester when needed, avoid dilatation unless essential); elderly (check for cancer and malnutrition); renal impairment (IV iron or erythropoiesis-stimulating agents under specialist care); adolescents (menstrual loss is a common cause).
• Red flags: progressive dysphagia, weight loss, odynophagia, haemoptysis, neck mass, stridor, anaemia not responding to iron, hoarseness.
• Follow-up: review at 4 to 8 weeks with haemoglobin and ferritin; repeat swallow assessment if symptoms persist; repeat dilatation for recurrence; long-term surveillance in Plummer-Vinson syndrome.