Esophageal webs and rings

Esophageal webs and rings are thin, membranous folds that can partially obstruct the esophagus. Webs are thin membranes of normal esophageal tissue that protrude into the proximal esophagus. Rings involve circumferential narrowing of the esophagus and are usually located in the distal esophagus. Webs are one of the triad in Plummer-Vinson syndrome alongside dysphagia and iron deficiency anemia. The most common type of esophageal ring is the Schatzki ring, which is associated with gastroesophageal reflux disease (GERD) and hiatal hernias. Many patients are asymptomatic. In symptomatic patients, the characteristic feature is intermittent dysphagia with solids; food bolus impaction is a common manifestation of Schatzki rings. Diagnosis is usually made with an esophageal barium swallow, which is superior to endoscopy for identifying webs and rings. Management is reserved for symptomatic patients and focuses on endoscopic dilation. Iron supplementation is a key treatment for Plummer-Vinson syndrome, while proton pump inhibitor (PPI) therapy is recommended after dilation of Schatzki rings to reduce recurrence. Plummer-Vinson syndrome increases the risk of squamous cell carcinoma of the pharynx and esophagus.

Definition ^[1]

An esophageal web is a thin, eccentric mucosal membrane that typically arises from the anterior wall of the proximal esophagus.

Epidemiology

The prevalence in individuals evaluated for dysphagia via barium swallow is 5–15%. ^[1]

Etiology ^[1][2]

• Idiopathic
• Associated conditions include:
  • Plummer-Vinson syndrome
  • Celiac disease
  • Zenker diverticulum
  • Cutaneous disorders (e.g., epidermolysis bullosa, pemphigus vulgaris, psoriasis)

Clinical features ^[1][4]

Patients are usually asymptomatic; clinical features in symptomatic patients include:

• Dysphagia: intermittent, predominantly with solids
• Odynophagia
• Choking sensation due to tracheal compression
• Weight loss (uncommon)

Diagnostics ^[1][4]

• Esophageal barium swallow: shows a thin, shelf-like filling defect projecting into the lumen in the proximal esophagus
• Esophagogastroduodenoscopy (EGD)
  • Less sensitive than esophageal barium swallow
  • Findings may include a thin, smooth, noncircumferential membrane in the proximal esophagus.

Esophageal barium swallow is the preferred initial test for suspected esophageal webs, although EGD is commonly performed first in the evaluation of dysphagia.

Differential diagnoses

See "Overview of causes of dysphagia."

Treatment ^[1][4]

Treatment is only indicated for symptomatic patients.

• Endoscopic dilation
  • Indicated for persistent symptoms
  • Repeat dilation is not usually required.
• Incision or resection: reserved for refractory disease
• Manage the underlying cause (e.g., treat IDA in Plummer-Vinson syndrome).

Definition ^[2]

Plummer-Vinson syndrome is defined by the triad of proximal esophageal webs, dysphagia, and iron deficiency anemia (IDA).

Epidemiology

• Most common in White, middle-aged women ^[2][5]
• Prevalence: 8.4–22.4% in women with dysphagia ^[5]

Clinical features ^[2]

• Dysphagia: intermittent or progressive over years, predominantly with solids
• Clinical features of IDA, including:
  • Fatigue and pallor
  • Atrophic glossitis
  • Angular cheilitis
  • Koilonychia
• Constitutional symptoms (e.g., weight loss)

DICEd Plumm - Dysphagia, Iron deficiency anemia, Carcinoma of the esophagus, Esophageal webs in Plummer-Vinson syndrome.

Diagnostics ^[2]

• Esophageal barium swallow or EGD to evaluate for esophageal webs
• Diagnostic studies for iron deficiency to confirm IDA

Management ^[2]

• Treat IDA.
• Consider endoscopic dilation for symptomatic esophageal webs.
• Ensure close clinical follow-up to monitor for squamous cell carcinoma of the esophagus or pharynx.

Iron supplementation typically improves dysphagia in Plummer-Vinson syndrome. ^[2]

Complications

Squamous cell carcinoma of the esophagus or pharynx occurs in 3–15% of patients. ^[2]

Definition ^[1]

An esophageal ring is a thin, circumferential narrowing of the esophageal lumen, usually in the distal esophagus.

Epidemiology

• Age: typically diagnosed in individuals > 40 years of age ^[4]
• Prevalence (for Schatzki rings, the most common type)
  • 0.2–14% in the general population ^[1]
  • 15–26% of individuals evaluated for dysphagia ^[1]

Etiology ^[1]

• Not fully understood
• Associated conditions include:
  • GERD
  • Hiatal hernia
  • Eosinophilic esophagitis

Classification ^[1][3]

Classification of esophageal rings is based on anatomical location.

• A ring: proximal to the squamocolumnar junction and caused by smooth muscle contractions
• B ring (Schatzki ring): at the squamocolumnar junction
• C ring: distal to the squamocolumnar junction and caused by diaphragmatic crural pressure

Clinical features ^[1][3][4]

Patients are usually asymptomatic; clinical features in symptomatic patients include:

• Dysphagia: intermittent, predominantly with solids
• Food bolus impaction
• Central chest pain
• Regurgitation
• Weight loss (uncommon)

Diagnostics ^[3][6]

• Esophageal barium swallow: shows a distal esophageal circumferential filling defect
• EGD
  • Less sensitive than esophageal barium swallow
  • Findings: a thin, smooth, circumferential ridge that narrows the lumen of the distal esophagus
  • Biopsies are indicated to evaluate for eosinophilic esophagitis if suspected.

Barium esophagram is the preferred initial test for suspected esophageal rings, although EGD is commonly performed first in the evaluation of dysphagia.

Differential diagnoses

See "Overview of causes of dysphagia."

Treatment ^[1][4]

Treatment is only indicated for symptomatic patients.

• Advise deliberate, thorough mastication.
• Endoscopic dilation: first-line treatment; repeat dilation may be required.
• Provide PPI therapy (e.g., omeprazole) after dilation to reduce recurrence. ^[7]
• Incision or resection: reserved for refractory disease

Complications ^[1]

• Food bolus impaction
• Esophageal perforation (very rare)