Esophageal web: Difference between revisions

Jump to navigation Jump to search
← Older editNewer edit →
VisualWikitext
Ahmed Younes (talk | contribs)
nocaptcha
6,168 edits
Ahmed Younes (talk | contribs)
nocaptcha
6,168 edits
No edit summary
Line 5: Line 5:
{{SK}} Oesophageal web
{{SK}} Oesophageal web
==Overview==
==Overview==
Esophageal webs are mucosal folds that partially obstructs the esophageal lumen. The exact pathogenesis of esophageal webs is not known but it is thought to be due to either esophageal inflammation, congenital anomaly, or iron deficiency. They can be classified into type A, B, and C according to their site and extent, type B being the most common. The most common causes are Plummer-Vinson syndrome, celiac sprue and Zenker’s diverticulum. Esophageal webs most commonly present with dysphagia that has a slow onset and is rarely complicated with weight loss. Esophageal webs must be differentiated from other causes of dysphagia such esophageal strictures and achalasia. In barium esophagram, esophageal webs appear as a uniform narrowing of the esophagus and on endoscopy, esophageal webs appear as a smooth narrowing of the esophagus that is not present in the whole circumference of the lumen. Esophageal dilation is the cornerstone of treatment and it is effective in relieving the symptoms but with high recurrence rate.
Esophageal webs are [[mucosal]] folds that partially obstructs the esophageal lumen. The exact pathogenesis of esophageal webs is not known but it is thought to be due to either esophageal [[inflammation]], [[congenital anomaly]], or [[iron deficiency]]. They can be classified into type A, B, and C according to their site and extent, type B being the most common. The most common causes are [[Plummer-Vinson syndrome]], [[celiac sprue]] and [[Zenker's diverticulum|Zenker’s diverticulum]]. Esophageal webs most commonly present with [[dysphagia]] that has a slow onset and is rarely complicated with [[weight loss]]. Esophageal webs must be differentiated from other causes of [[dysphagia]] such esophageal strictures and [[achalasia]]. In [[Esophagogram|barium esophagogram]], esophageal webs appear as a uniform narrowing of the esophagus and on [[endoscopy]], esophageal webs appear as a smooth narrowing of the esophagus that is not present in the whole circumference of the lumen. Esophageal dilation is the cornerstone of treatment and it is effective in relieving the symptoms but with high recurrence rate.


==Historical perspective==
==Historical perspective==
*In 1944, esophageal webs were first described by Templeton and it was thought to be a congenital disease because most of the patients were children.<ref name="pmid3412097">{{cite journal |vauthors=Okamura H, Tsutsumi S, Inaki S, Mori T |title=Esophageal web in Plummer-Vinson syndrome |journal=Laryngoscope |volume=98 |issue=9 |pages=994–8 |year=1988 |pmid=3412097 |doi=10.1288/00005537-198809000-00014 |url=}}</ref>
*In 1944, esophageal webs were first described by Templeton and it was thought to be a [[congenital disease]] because most of the patients were children.<ref name="pmid3412097">{{cite journal |vauthors=Okamura H, Tsutsumi S, Inaki S, Mori T |title=Esophageal web in Plummer-Vinson syndrome |journal=Laryngoscope |volume=98 |issue=9 |pages=994–8 |year=1988 |pmid=3412097 |doi=10.1288/00005537-198809000-00014 |url=}}</ref>
*In 1953, a series of case reports of patients having dysphagia and radiological signs denoting esophageal narrowing made the diagnosis of esophageal rings not confined to the pediatric population.
*In 1953, a series of case reports of patients having [[dysphagia]] and radiological signs denoting esophageal narrowing made the diagnosis of esophageal rings not confined to the pediatric population.
*In 1968, histological examination of specimens from the esophageal rings proved that none of them had muscle involvement.<ref name="pmid13904659">{{cite journal |vauthors=HARDY JD, CONN JH |title=Diseases of the esophagus: an analysis of 308 consecutive cases |journal=Ann. Surg. |volume=155 |issue= |pages=971–90 |year=1962 |pmid=13904659 |pmc=1466157 |doi= |url=}}</ref>
*In 1968, histological examination of specimens from the esophageal rings proved that none of them had [[muscle]] involvement.<ref name="pmid13904659">{{cite journal |vauthors=HARDY JD, CONN JH |title=Diseases of the esophagus: an analysis of 308 consecutive cases |journal=Ann. Surg. |volume=155 |issue= |pages=971–90 |year=1962 |pmid=13904659 |pmc=1466157 |doi= |url=}}</ref>


==Classification==
==Classification==
Line 20: Line 20:


===Type B===
===Type B===
*Type B esophageal rings describe the webs that involve only the mucosa and submucosa of the esophagus.
*Type B esophageal rings describe the webs that involve only the [[mucosa]] and [[submucosa]] of the esophagus.
*It is often named “Schatzki ring”.
*It is often named “[[Schatzki ring]]”.
*It is located exactly at the squamocolumnar junction.
*It is located exactly at the squamocolumnar junction.


===Type C===
===Type C===
*Type C esophageal rings refer to wall invaginations due to pressure from the diaphragm.
*Type C esophageal rings refer to wall invaginations due to pressure from the [[diaphragm]].
*It is rare with no clinical significance.
*It is rare with no clinical significance.


Line 33: Line 33:


====Inflammation====
====Inflammation====
*Esophageal webs are thought to be due to the chronic damage to the esophageal mucosa.
*Esophageal webs are thought to be due to the chronic damage to the [[Mucosa|esophageal mucosa]].
*This is supported by the presence of inflammatory cells in the wall of the web.<ref name="pmid3412097">{{cite journal |vauthors=Okamura H, Tsutsumi S, Inaki S, Mori T |title=Esophageal web in Plummer-Vinson syndrome |journal=Laryngoscope |volume=98 |issue=9 |pages=994–8 |year=1988 |pmid=3412097 |doi=10.1288/00005537-198809000-00014 |url=}}</ref>
*This is supported by the presence of [[inflammatory cells]] in the wall of the web.<ref name="pmid3412097">{{cite journal |vauthors=Okamura H, Tsutsumi S, Inaki S, Mori T |title=Esophageal web in Plummer-Vinson syndrome |journal=Laryngoscope |volume=98 |issue=9 |pages=994–8 |year=1988 |pmid=3412097 |doi=10.1288/00005537-198809000-00014 |url=}}</ref>
*In allergic esophagitis, eosinophils were found while in cases of chronic inflammation as GERD, lymphocytes prevailed.
*In [[eosinophilic esophagitis]], [[eosinophils]] were found while in cases of [[chronic inflammation]] as [[GERD]], [[lymphocytes]] prevailed.


====Congenital theory====
====Congenital theory====
*Esophageal webs are thought to be due to failure of the esophagus to recanalize.
*Esophageal webs are thought to be due to failure of the esophagus to recanalize.
*Specimens showed that the esophageal webs contained respiratory epithelium supporting this theory.<ref name="pmid18554241">{{cite journal |vauthors=Sinha SK, Nain CK, Udawat HP, Prasad KK, Das R, Nagi B, Singh K |title=Cervical esophageal web and celiac disease |journal=J. Gastroenterol. Hepatol. |volume=23 |issue=7 Pt 1 |pages=1149–52 |year=2008 |pmid=18554241 |doi=10.1111/j.1440-1746.2008.05452.x |url=}}</ref>
*Specimens showed that the esophageal webs contained [[respiratory epithelium]] supporting this theory.<ref name="pmid18554241">{{cite journal |vauthors=Sinha SK, Nain CK, Udawat HP, Prasad KK, Das R, Nagi B, Singh K |title=Cervical esophageal web and celiac disease |journal=J. Gastroenterol. Hepatol. |volume=23 |issue=7 Pt 1 |pages=1149–52 |year=2008 |pmid=18554241 |doi=10.1111/j.1440-1746.2008.05452.x |url=}}</ref>
*The webs mostly remain asymptomatic for long times and that is why it is not correlated with being congenital.
*The webs mostly remain asymptomatic for long times and that is why it is not correlated with being [[congenital]].


====Iron deficiency====
====Iron deficiency====
*The esophageal webs of Plummer-Vinson syndrome have been associated with iron deficiency anemia in many studies.
*The esophageal webs of [[Plummer-Vinson syndrome]] have been associated with [[iron deficiency anemia]] in many studies.
*The exact mechanism by which iron deficiency causes esophageal webs is not known, but it was hypothesized that iron deficiency starts a sequence of events in the esophageal epithelium that ends in its damage and formation of a web.<ref name="pmid8902418">{{cite journal |vauthors=DeVault KR |title=Lower esophageal (Schatzki's) ring: pathogenesis, diagnosis and therapy |journal=Dig Dis |volume=14 |issue=5 |pages=323–9 |year=1996 |pmid=8902418 |doi= |url=}}</ref>
*The exact mechanism by which [[iron deficiency]] causes esophageal webs is not known, but it was hypothesized that [[iron deficiency]] starts a sequence of events in the esophageal epithelium that ends in its damage and formation of a web.<ref name="pmid8902418">{{cite journal |vauthors=DeVault KR |title=Lower esophageal (Schatzki's) ring: pathogenesis, diagnosis and therapy |journal=Dig Dis |volume=14 |issue=5 |pages=323–9 |year=1996 |pmid=8902418 |doi= |url=}}</ref>
*Moreover, treatment of iron deficiency in Plummer-Vinson syndrome patients leads to resolution of dysphagia even before the laboratory results become normal.
*Moreover, treatment of [[iron deficiency]] in [[Plummer-Vinson syndrome]] patients leads to resolution of [[dysphagia]] even before the laboratory results become normal.


===Gross picture===
===Gross picture===
Line 51: Line 51:


===Microscopic picture===
===Microscopic picture===
*Esophageal webs are covered normally by mucosa and submucosa.
*Esophageal webs are covered normally by [[mucosa]] and [[submucosa]].
*It is characterized by the presence of basal cell hyperplasia.
*It is characterized by the presence of [[Hyperplasia|basal cell hyperplasia]].
*The tissue is often heavily infiltrated with chronic inflammatory cells.
*The tissue is often heavily infiltrated with [[Chronic inflammation|chronic inflammatory cells]].
*Eosinophilic esophagitis is characterized by the presence of eosinophils infiltration.
*[[Eosinophilic esophagitis]] is characterized by the presence of [[eosinophil]] infiltration.


==Causes==
==Causes==
===More common causes===
===More common causes===
*Iron deficiency anemia
*[[Iron deficiency anemia]]
*Plummer-Vinson syndrome
*[[Plummer-Vinson syndrome]]
*[[Celiac sprue]]
*[[Celiac sprue]]
*[[Zenker's diverticulum|Zenker’s diverticulum]]
*[[Zenker's diverticulum|Zenker’s diverticulum]]
Line 403: Line 403:
==Epidemiology==
==Epidemiology==
===Prevalence===
===Prevalence===
*Webs are diagnosed in 5-15% of patients doing barium esophagogram for diagnosing the cause of dysphagia.
*Webs are diagnosed in 5-15% of patients doing [[Esophagogram|barium esophagogram]] for diagnosing the cause of [[dysphagia]].
*Congenital esophageal webs are estimated to be 1 in 25,000 to 1 in 50,000 live births.
*Congenital esophageal webs are estimated to be 1 in 25,000 to 1 in 50,000 live births.


Line 411: Line 411:
===Sex===
===Sex===
*Esophageal webs tend to be more common in females.
*Esophageal webs tend to be more common in females.
*This may be due to the increased prevalence of iron deficiency anemia.
*This may be due to the increased prevalence of [[iron deficiency anemia]].


===Age===
===Age===
Line 422: Line 422:
===Natural history===
===Natural history===
*The disease can start at any age but symptoms usually start in the fifth decade of life.
*The disease can start at any age but symptoms usually start in the fifth decade of life.
*The dysphagia is usually to solids at the beginning then it progresses to both solids and liquids.
*The [[dysphagia]] is usually to solids at the beginning then it progresses to both solids and liquids.
*If left untreated, the webs may progress causing esophageal strictures and esophageal carcinoma.
*If left untreated, the webs may progress causing esophageal strictures and [[esophageal carcinoma]].


===Complications===
===Complications===
*Progression to esophageal carcinoma.
*Progression to [[esophageal carcinoma]].
*Choking spells
*Choking spells
*Esophagitis from chronic injury of the mucosa
*[[Esophagitis]] from chronic injury of the [[mucosa]]
*Progression to esophageal stricture
*Progression to [[esophageal stricture]]


===Prognosis===
===Prognosis===
*The prognosis of esophageal webs is generally good especially with treatment of the underlying cause.
*The prognosis of esophageal webs is generally good especially with treatment of the underlying cause.
*One of out of ten patients with Plummer-Vinson syndrome will develop esophageal carcinoma.
*One of out of ten patients with [[Plummer-Vinson syndrome]] will develop [[esophageal carcinoma]].


==History and symptoms==
==History and symptoms==
===History===
===History===
*Patients are usually older than 40 years because it can be asymptomatic for a long time.
*Patients are usually older than 40 years because it can be asymptomatic for a long time.
*The patient may give a history of the cause such as iron deficiency anemia, GERD, or autoimmune disease.
*The patient may give a history of the cause such as [[iron deficiency anemia]], [[GERD]], or [[autoimmune disease]].
*There may be a history of excessive food chewing to facilitate swallowing.
*There may be a history of excessive food chewing to facilitate swallowing.
===Symptoms===
===Symptoms===
*Most of the esophageal webs are asymptomatic.
*Most of the esophageal webs are asymptomatic.
*The major symptom of esophageal webs is dysphagia.
*The major symptom of esophageal webs is [[dysphagia]].
*Dysphagia is usually more for solid food.
*[[Dysphagia]] is usually more for solid food.
*Esophageal webs do not usually result in malnutrition nor to weight loss.
*Esophageal webs do not usually result in [[malnutrition]] nor to [[weight loss]].


==Physical examination==
==Physical examination==
Esophageal webs do not have significant physical exam findings, however, it might show the signs of the cause such as
Esophageal webs do not have significant physical exam findings, however, it might show the signs of the cause such as
*Koilonychia and glossitis in the cases of Plummer-Vinson syndrome.
*[[Koilonychia]] and glossitis in the cases of [[Plummer-Vinson syndrome]].
*It might also show the findings in in the cases of skin disorders such as epidermolysis bullosa, bullous pemphigoid, and pemphigus vulgaris.
*It might also show the findings in in the cases of skin disorders such as [[epidermolysis bullosa]], [[bullous pemphigoid]], and [[pemphigus vulgaris]].


==Lab findings==
==Lab findings==
*A Laboratory workup is not necessary for the diagnosis of esophageal webs because the diagnosis is dependent on the symptoms and radiological tests.
*A Laboratory workup is not necessary for the diagnosis of esophageal webs because the diagnosis is dependent on the symptoms and radiological tests.
*CBC might show microcytic hypochromic anemia in cases of Plummer-Vinson syndrome as it is the primary cause of the esophageal web.
*[[CBC]] might show [[Anemia|microcytic hypochromic anemia]] in cases of [[Plummer-Vinson syndrome]] as it is the primary cause of the esophageal web.
*Antibody panel might be done to screen for the primary cause.
*[[Antibody|Antibody panel]] might be done to screen for the primary cause.


==Radiological tests==
==Radiological tests==
===Barium esophagogram===
===Barium esophagogram===
*It is more sensitive in detecting esophageal webs than endoscopy.
*[[Esophagogram|Barium esophagogram]] is more sensitive in detecting esophageal webs than [[endoscopy]].
*Webs appear as a uniform narrowing of the esophageal lumen.
*Webs appear as a uniform narrowing of the esophageal lumen.
===Other diagnostic tests===
===Other diagnostic tests===
====Endoscopy====
====Endoscopy====
*Endoscopy is less sensitive in detecting webs than barium esophagram.
*[[Endoscopy]] is less sensitive in detecting webs than [[Esophagogram|barium esophagram]].
*Esophageal webs appear as a smooth membrane that is not encircling the whole lumen.
*Esophageal webs appear as a smooth membrane that is not encircling the whole lumen.
*It allows obtaining a biopsy from the lesion in addition to excluding other causes of dysphagia.
*It allows obtaining a [[biopsy]] from the lesion in addition to excluding other causes of [[dysphagia]].
*Esophageal webs can go unnoticed during the esophagram as it is only a mucous membrane fold with no muscle support.
*Esophageal webs can go unnoticed during the esophagram as it is only a [[mucous membrane]] fold with no muscle support.


==Treatment==
==Treatment==
===Medical therapy===
===Medical therapy===
*Patients should be educated to change their diet and food habits, especially in the cases when esophageal webs are secondary to GERD.
*Patients should be educated to change their diet and food habits, especially in the cases when esophageal webs are secondary to [[GERD]].
*H2 blockers or proton pump inhibitors can be used for managing the symptoms of GERD and the prevention of progression to webs.
*[[Ranitidin|H2 blockers]] or [[proton pump inhibitors]] can be used for managing the symptoms of [[GERD]] and the prevention of progression to webs.
*Proper management of acid reflux after esophageal dilation is associated with decreased recurrence of symptoms.  
*Proper management of [[acid reflux]] after esophageal dilation is associated with decreased recurrence of symptoms.  
===Surgical therapy===
===Surgical therapy===
*Esophageal dilation is the cornerstone of treating esophageal webs especially in cases refractory to medical treatment.
*Esophageal dilation is the cornerstone of treating esophageal webs especially in cases refractory to medical treatment.
*In cases of eosinophilic esophagitis, dilation should be gradual as sudden forced dilation is associated with muscle tears.
*In cases of [[eosinophilic esophagitis]], dilation should be gradual as sudden forced dilation is associated with muscle tears.
*In cases of non-eosinophilic esophagitis, dilation using a single dilator is more effective than graded dilation.
*In cases of non-eosinophilic esophagitis, dilation using a single dilator is more effective than graded dilation.
*Esophageal dilation is associated with improved symptoms of dysphagia.
*Esophageal dilation is associated with improved [[dysphagia]].
*Esophageal dilation is associated with symptom recurrence in about 89% at five years and often requires redoing of the procedure.
*Esophageal dilation is associated with symptom recurrence in about 89% at five years and often requires redoing of the procedure.
==References==
==References==
{{reflist|2}}
{{reflist|2}}

Revision as of 23:01, 20 November 2017

Esophageal web Main page

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Esophageal web from other Diseases

Epidemiology

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

History and Symptoms

Physical Examination

Laboratory Findings

Radiological tests

Other Diagnostic Studies

Treatment

Medical therapy

Surgerical therapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Ahmed Younes M.B.B.CH [2]

Synonyms and keywords: Oesophageal web

Overview

Esophageal webs are mucosal folds that partially obstructs the esophageal lumen. The exact pathogenesis of esophageal webs is not known but it is thought to be due to either esophageal inflammation, congenital anomaly, or iron deficiency. They can be classified into type A, B, and C according to their site and extent, type B being the most common. The most common causes are Plummer-Vinson syndrome, celiac sprue and Zenker’s diverticulum. Esophageal webs most commonly present with dysphagia that has a slow onset and is rarely complicated with weight loss. Esophageal webs must be differentiated from other causes of dysphagia such esophageal strictures and achalasia. In barium esophagogram, esophageal webs appear as a uniform narrowing of the esophagus and on endoscopy, esophageal webs appear as a smooth narrowing of the esophagus that is not present in the whole circumference of the lumen. Esophageal dilation is the cornerstone of treatment and it is effective in relieving the symptoms but with high recurrence rate.

Historical perspective

  • In 1944, esophageal webs were first described by Templeton and it was thought to be a congenital disease because most of the patients were children.[1]
  • In 1953, a series of case reports of patients having dysphagia and radiological signs denoting esophageal narrowing made the diagnosis of esophageal rings not confined to the pediatric population.
  • In 1968, histological examination of specimens from the esophageal rings proved that none of them had muscle involvement.[2]

Classification

Esophageal webs can be classified according to their site and extent in three categories[3] [4][5]

Type A

  • Type A esophageal rings describe webs that involve the muscle layer of the esophageal wall and lies in close proximity to the squamocolumnar junction.
  • It is less common than type B esophageal webs.

Type B

  • Type B esophageal rings describe the webs that involve only the mucosa and submucosa of the esophagus.
  • It is often named “Schatzki ring”.
  • It is located exactly at the squamocolumnar junction.

Type C

  • Type C esophageal rings refer to wall invaginations due to pressure from the diaphragm.
  • It is rare with no clinical significance.

Pathophysiology

Pathogenesis

There are multiple theories explaining the origin of esophageal webs

Inflammation

Congenital theory

  • Esophageal webs are thought to be due to failure of the esophagus to recanalize.
  • Specimens showed that the esophageal webs contained respiratory epithelium supporting this theory.[6]
  • The webs mostly remain asymptomatic for long times and that is why it is not correlated with being congenital.

Iron deficiency

Gross picture

  • Esophageal webs appear as an eccentric narrowing of the esophageal lumen (while rings cause circumferential narrowing).

Microscopic picture

Causes

More common causes

Less common causes

Differentiating esophageal webs from other diseases

Esophageal webs must be differentiated from other causes of dysphagia such as achalasia and esophageal carcinoma.

Disease Signs and Symptoms Barium esophagogram Endoscopy Other imaging and laboratory findings Gold Standard
Onset Dysphagia Weight loss Heartburn Other findings Mental status
Solids Liquids Type
Plummer-Vinson syndrome
  • Gradual
 + - Non progressive +/- - Normal
Barium esophagogram (Source: Case courtesy of Dr Hani Salam, <a href="https://radiopaedia.org/">Radiopaedia.org</a>. From the case <a href="https://radiopaedia.org/cases/14029">rID: 14029</a>)
{{#ev:youtube|HFfsTgsB6Pg}}

Triad of

Esophageal stricture
  • Gradual
  • Sudden onset
 + - Progressive +/- +/- Normal
  • Sacculations
  • Fixed transverse folds
  • Esophageal intramural pseudodiverticula   
Case courtesy of Dr Ahmed Abd Rabou, Radiopaedia.org, rID: 23008
{{#ev:youtube|vax5E-jMnQ}}
Diffuse esophageal spasm
  • Sudden
 + + Non progressive + + Normal
  • Nonperistaltic and nonpropulsive contractions
  • Corkscrew or rosary bead esophagus
Barium swallow appearance of DES
Source:By Nevit Dilmen [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)
  • Inconclusive
{{#ev:youtube|2ipA34iMA3c}}
Achalasia
  • Gradual
 + + Non progressive +/- - Normal
  • "Bird's beak" or "rat tail" appearance
  • Dilated esophageal body
  • Air fluid level (absent peristalsis)
  • Absence of an intragastric air bubble
Case courtesy of Dr Mario Umana, Radiopaedia.org, rID: 38071
{{#ev:youtube|ydLcskQzEjM}}
  • Residual pressure of LES > 10 mmHg
  • Incomplete relaxation of the LES
  • Increased resting tone of LES
  • Aperistalsis
Systemic sclerosis
  • Gradual
 + + Progressive +/- + Normal
  • Dysmotility
  • Peptic stricture (advanced cases)
 Positive serology for
Zenker's diverticulum
  • Gradual
 + - +/- - Normal
Radiopaedia.org">"Zenker diverticulum | Radiology Case | Radiopaedia.org".</ref>
  • Exclude the presence of SCC
{{#ev:youtube|FdEruFsNdVA}}
 
  • CT & MRI shows out-pouching over the posterior esophagus in the Killian's triangle
Esophageal carcinoma
  • Gradual
 + + Progressive + +/- Normal
Case courtesy of Dr Bruno Di Muzio, Radiopaedia.org, rID: 4232f
{{#ev:youtube|5ucSlgqGAno}}
  • CT and PET scan is an optional test for staging of the disease
Stroke

(Cerebral hemorrhage)

  • Sudden
 + + Progressive + +/- Impaired
Motor disorders

(Myasthenia gravis)

  • Gradual
 + + Progressive +/- Normal
  • Stasis in pharynx and pooling in pharyngeal recesses
  • Anti–acetylcholine receptor antibody test
GERD
  • Gradual
  • Sudden onset
 + - Progressive +/- + Normal
Esophageal web
  • Gradual
 + +/- Progressive - +/- Normal
  • Smooth membrane not encircling the whole lumen

Epidemiology

Prevalence

  • Webs are diagnosed in 5-15% of patients doing barium esophagogram for diagnosing the cause of dysphagia.
  • Congenital esophageal webs are estimated to be 1 in 25,000 to 1 in 50,000 live births.

Race

  • Esophageal webs affects the whites more than other population

Sex

  • Esophageal webs tend to be more common in females.
  • This may be due to the increased prevalence of iron deficiency anemia.

Age

  • Esophageal has no predilection for an age group, however, it is usually not symptomatic until after the age of 40.

Screening

According to USPSTF, there are no screening measures recommended for esophageal webs.

Natural history, complications and prognosis

Natural history

  • The disease can start at any age but symptoms usually start in the fifth decade of life.
  • The dysphagia is usually to solids at the beginning then it progresses to both solids and liquids.
  • If left untreated, the webs may progress causing esophageal strictures and esophageal carcinoma.

Complications

Prognosis

History and symptoms

History

  • Patients are usually older than 40 years because it can be asymptomatic for a long time.
  • The patient may give a history of the cause such as iron deficiency anemia, GERD, or autoimmune disease.
  • There may be a history of excessive food chewing to facilitate swallowing.

Symptoms

  • Most of the esophageal webs are asymptomatic.
  • The major symptom of esophageal webs is dysphagia.
  • Dysphagia is usually more for solid food.
  • Esophageal webs do not usually result in malnutrition nor to weight loss.

Physical examination

Esophageal webs do not have significant physical exam findings, however, it might show the signs of the cause such as

Lab findings

Radiological tests

Barium esophagogram

  • Barium esophagogram is more sensitive in detecting esophageal webs than endoscopy.
  • Webs appear as a uniform narrowing of the esophageal lumen.

Other diagnostic tests

Endoscopy

  • Endoscopy is less sensitive in detecting webs than barium esophagram.
  • Esophageal webs appear as a smooth membrane that is not encircling the whole lumen.
  • It allows obtaining a biopsy from the lesion in addition to excluding other causes of dysphagia.
  • Esophageal webs can go unnoticed during the esophagram as it is only a mucous membrane fold with no muscle support.

Treatment

Medical therapy

  • Patients should be educated to change their diet and food habits, especially in the cases when esophageal webs are secondary to GERD.
  • H2 blockers or proton pump inhibitors can be used for managing the symptoms of GERD and the prevention of progression to webs.
  • Proper management of acid reflux after esophageal dilation is associated with decreased recurrence of symptoms.

Surgical therapy

  • Esophageal dilation is the cornerstone of treating esophageal webs especially in cases refractory to medical treatment.
  • In cases of eosinophilic esophagitis, dilation should be gradual as sudden forced dilation is associated with muscle tears.
  • In cases of non-eosinophilic esophagitis, dilation using a single dilator is more effective than graded dilation.
  • Esophageal dilation is associated with improved dysphagia.
  • Esophageal dilation is associated with symptom recurrence in about 89% at five years and often requires redoing of the procedure.

References

  1. ↑ 1.0 1.1 Okamura H, Tsutsumi S, Inaki S, Mori T (1988). "Esophageal web in Plummer-Vinson syndrome". Laryngoscope. 98 (9): 994–8. doi:10.1288/00005537-198809000-00014. PMID 3412097.
  2. ↑ HARDY JD, CONN JH (1962). "Diseases of the esophagus: an analysis of 308 consecutive cases". Ann. Surg. 155: 971–90. PMC 1466157. PMID 13904659.
  3. ↑ Smith MS (2010). "Diagnosis and management of esophageal rings and webs". Gastroenterol Hepatol (N Y). 6 (11): 701–4. PMC 3033540. PMID 21437018.
  4. ↑ Mann NS, Leung JW (2005). "Pathogenesis of esophageal rings in eosinophilic esophagitis". Med. Hypotheses. 64 (3): 520–3. doi:10.1016/j.mehy.2004.08.021. PMID 15617859.
  5. ↑ Pleet JL, Taboada S, Rishi A, Milman PJ, Trindade AJ (2017). "Rings in the esophagus are not always eosinophilic esophagitis: Case series of ring forming lymphocytic esophagitis and review of the literature". Endosc Int Open. 5 (6): E484–E488. doi:10.1055/s-0043-106579. PMC 5451283. PMID 28573181.
  6. ↑ Sinha SK, Nain CK, Udawat HP, Prasad KK, Das R, Nagi B, Singh K (2008). "Cervical esophageal web and celiac disease". J. Gastroenterol. Hepatol. 23 (7 Pt 1): 1149–52. doi:10.1111/j.1440-1746.2008.05452.x. PMID 18554241.
  7. ↑ DeVault KR (1996). "Lower esophageal (Schatzki's) ring: pathogenesis, diagnosis and therapy". Dig Dis. 14 (5): 323–9. PMID 8902418.
Retrieved from "https://www.wikidoc.org/index.php?title=Esophageal_web&oldid=1391460"