THE PATERSON-KELLY SYNDROME

Iron deficiency anemia and Plummer-Vinson syndrome: current insights

Plummer–Vinson syndrome (PVS), a rare clinical condition, is characterized by a triad of dysphagia, iron deficiency anemia and esophageal web in the post-cricoid region. It was first described over a century ago. However, literature on this condition remains scanty, and 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 women. The esophageal webs in PVS are thin mucosal folds, which are best seen either in lateral views at barium swallow or at esophagoscopy. These are usually semilunar or crescentic, being located most often along the anterior esophageal wall, but can be concentric. The exact cause and pathogenesis of PVS remain unclear, though iron and other nutritional deficiencies, genetic predisposition and autoimmunity have all been implicated in formation of the webs. Treatment includes correction of iron deficiency and endoscopic dilation of the esophageal webs to relieve dysphagia. PVS is associated with an increased risk of hypopharyngeal and esophageal malignancies. Correction of iron deficiency may arrest and reverse the mucosal changes and possibly reduces this risk.

Single-center prospective study of Plummer-Vinson syndrome

Post-cricoid web is an uncommon cause for dysphagia and is most frequently reported in middle-aged women. Triad of web, iron deficiency anemia (IDA), and dysphagia is known as Plummer-Vinson syndrome (PVS). Literature on PVS is very limited. Here we report the first prospective study of PVS with predefined diagnostic criteria and management plan. Adults with dysphagia or those incidentally found to have esophageal web were prospectively enrolled between July 2011 and June 2013. Participants were evaluated with hemogram, barium swallow, and esophagogastroduodenoscopy. PVS was diagnosed if a person had IDA and a post-cricoid web in barium swallow and/or endoscopy. Patients were managed with dilation using through-the-scope controlled radial expansion balloon followed by oral iron and folic acid supplementation. Thirty-seven patients (age, median [range] 40 [19-65] years; 32 [86%] women) were enrolled. Thirty-one symptomatic patients had dysphagia grade 1 (n = 12, 39%), 2 (n = 13, 42%), and 3 (n = 6, 19%) for a median (range) duration of 24 (4-324) months. Barium swallow, done in 29, showed web in 25 which were either circumferential or anterior in position. Twenty-nine (29/31, 94%) patients had complete and two had partial response after the first session of endoscopic dilatation without any complication. Dysphagia recurred in three (10%) of the 30 patients who were followed for a median (range) of 10 (1-24) months. Esophageal-web related dysphagia in patients with PVS responds favorably after single session of endoscopic dilation.

Role of microsatellites instability in carcinogenesis of postcricoid carcinoma on top of plummer-vinson syndrome

To develop a molecular pattern that might help in understanding carcinogenesis of postcricoid carcinoma (PCC) on top of Plummer-Vinson syndrome (PVS) in a prospective controlled study. Twenty-four patients with PVS were diagnosed and followed up over a 4 year period, during which eight of them showed malignant change to PCC. Twenty volunteers free of neoplastic diseases were included as a control group. In the two groups, DNA extraction from mononuclear peripheral blood cells, and analysis of loss of heterozygosity (LOH) and microsatellite instability (MSI) using six paired simple tandem repeats (STRs) primers were done. The molecular weight of each STRs locus was scored and statistical correlations were performed. LOH occurred in 55.6 and 72.9% of PVS and PCC cases compared to 25% of control group. At loci D17S695, D9S753 and D9S171, LOH occurred in 54.2, 66.7, and 70.8% of PVS cases; and in 62.5% of PCC cases for each locus compared to 15, 25 and 45% of control cases. D3S1286 and CFS1-R displayed the highest frequency of LOH in PCC (100% for each) while recorded in 58.3 and 33.3% in PVS compared to 30 and 0% in control cases. Certain genetic events tend to occur as early and late events in malignant change of PVS to PCC. Detection of these events may help in understanding carcinogenesis and in early detection of malignancy. CFS1-R is the most informative marker of tumor progression.

Cervical esophageal web and celiac disease

BACKGROUND AND AIM

There is paucity of prospective data on association between cervical esophageal webs and celiac disease. It is not clear whether all patients with cervical esophageal web need screening for celiac disease. Hence, the present study was carried out to determine the association of cervical esophageal web with celiac disease.

METHODS

This prospective study included consecutive patients with symptomatic cervical esophageal web diagnosed over a period of 4.5 years. Tissue transglutaminase antibody was measured in serum of each patient. Patients with elevated tissue transglutaminase antibody titer were subjected to esophagogastroduodenoscopy and biopsies were obtained from the descending duodenum to look for histological changes of celiac disease. Esophageal web was treated with bougie dilatation. Celiac disease was diagnosed on the basis of elevated tissue transglutaminase antibody and suggestive duodenal histology.

RESULTS

Twenty one patients were diagnosed to have cervical esophageal web. Eighteen (85.7%) had evidence of iron deficiency. Five (23.8%) patients with cervical esophageal web fulfilled criteria for diagnosis of celiac disease. All five had evidence of iron deficiency. None of these patients gave a history of chronic diarrhea. All patients were treated with bougie dilatation. Patients with celiac disease were advised of a gluten-free diet. All five celiac disease patients are free of dysphagia without recurrence after a mean follow up of 10 months (range: 3 to 16 months).

CONCLUSIONS

There is association between cervical esophageal web and celiac disease. All adult patients with cervical esophageal web and iron deficiency need screening for celiac disease even in the absence of chronic diarrhea.

Plummer-Vinson syndrome heralded by postcricoid carcinoma

Plummer-Vinson syndrome is one of the names given to the constellation of dysphagia, iron-deficiency anemia, and esophageal webbing. Treatment consists of iron supplementation, possibly dilation, and surveillance. The syndrome is associated with an increased risk of postcricoid carcinoma, which usually presents at an advanced stage. We present a case of an early postcricoid carcinoma that led to the diagnosis of Plummer-Vinson syndrome and subsequent treatment of both conditions.

Plummer-Vinson syndrome associated with chronic blood loss anemia and large diaphragmatic hernia

The coexistence of large diaphragmatic hernia and Plummer-Vinson syndrome in two patients is described. It is proposed that the hernias caused chronic blood loss anemia, and that iron deficiency then resulted in postcricoid web formation.

A case of Plummer-Vinson syndrome in childhood

The Plummer-Vinson syndrome is characterized by an association of dysphagia, iron-deficiency anemia, and esophageal webs. The authors report the case of a 6 year old with Plummer-Vinson syndrome. Plummer-Vinson syndrome usually occurs in adults, rarely in adolescents, however, there have been no previous reports in the English-language literature of the syndrome occurring in childhood.

Celiac disease presenting as the Paterson-Brown Kelly (Plummer-Vinson) syndrome

We describe two patients with Paterson-Brown Kelly (Plummer-Vinson) syndrome whose iron deficiency anemia was due to celiac disease. They presented with dysphagia 13 and 9 yr, respectively, before celiac disease was diagnosed. Neither had gastrointestinal symptoms suggestive of malabsorption. Celiac disease is a recognized cause of chronic iron deficiency and should be considered as an etiological factor for sideropenic dysphagia.

Esophageal rings, webs, and diverticula

Rings, webs, and diverticula are among the most common anatomic anomalies of the esophagus. Although these structural lesions are often asymptomatic, patients can develop significant problems with dysphagia, regurgitation, and aspiration. This article discusses the epidemiology, pathogenesis, diagnosis, and therapy of esophageal rings, webs, and diverticula with emphasis on the clinical, diagnostic, and therapeutic strategies involved in caring for patients with these conditions.

Rise and fall of the Plummer-Vinson syndrome

Three hypotheses have been proposed for the decreased incidence of Plummer-Vinson disease: non-existence, identity with inlet gastric mucosa of the oesophagus and disappearance of the predisposing condition(s). We examined these possibilities by reviewing our understanding of the syndrome. The early framers disagreed on the cause, but many thought it was a precursor for upper oesophageal carcinoma. Four explanations arose to account for the pathogenesis: iron deficiency; nutritional deficits; autoimmunity; and gastric lesion. We believe the decline in recognition paralleled the improve of dietary status and the treatment of sideropenic anaemia with inorganic iron salts.

Esophageal motility impairment in Plummer-Vinson syndrome. Correction by iron treatment

We report the case of a 41-year-old woman with Plummer-Vinson syndrome and an esophageal motility disorder. She complained of dysphagia and odynophagia and had cheilitis, glossitis, and hypochromic anemia. An esophageal motility study showed low amplitude of contraction and high intrabolus pressure in the esophageal body. After iron replacement, the patient was free from symptoms, and a new motility study showed increased amplitude of contraction and decreased intrabolus pressure.

Latent iron deficiency alters gamma-aminobutyric acid and glutamate metabolism in rat brain

A diet containing 18-20 mg iron/kg to young weaned rats for 8 weeks altered the metabolism of gamma-aminobutyric acid and glutamate in the central nervous system without affecting blood hemoglobin. Subsequent rehabilitation with 390 mg iron/kg diet for 2 weeks normalized these changes.

Iron deficiency in the elderly

Iron deficiency in the elderly almost always results from blood loss. The loss of iron can be viewed as occurring in four stages, which are reflected in the different tests used to diagnose iron deficiency. Tests used to diagnose iron deficiency have certain limitations regarding their ability to detect iron deficiency before the overt anaemia occurs. The tests which diagnose iron deficiency most accurately are low serum ferritin and reduced iron staining of a bone marrow aspirate. Because iron is present in many metabolic processes besides the production of haemoglobin, iron deficiency results in a variety of defects which are manifested at biochemical, tissue, and functional levels. Iron is a component of several enzymes in the respiratory electron transport chain. Adequate haem and iron levels are necessary to control cytoplasmic and mitochondrial protein synthesis. Iron deficiency results in tissue defects, including those affecting the gastrointestinal tract, and defects of mitochondria and lymphocytes. Normal iron levels seem to be necessary for normal work capacity. A deficiency of iron, independent of the anaemia, results in reduced exercise capacity that can be measured in both physiological and economic terms. Elderly patients complaining of increased fatigue should therefore be screened for iron deficiency. There is evidence to suggest that iron deficiency may predispose individuals to certain infections. Other information points to the promotion of certain bacterial and parasitic infections after rapid correction of iron deficiency. Thus elderly patients having iron replacement therapy should be followed closely. A deficiency of iron has been shown to result in certain behavioural and learning abnormalities. Iron deficiency has been shown to result in impaired control of body temperature, resulting in an increase in catecholamine levels. The impairment in heat-generating ability was shown to result from reduced conversion of T4 to T3 in the peripheral tissues.

Iron deficiency and iron overload

An up to date review of our knowledge of human iron metabolism is given including problems of iron balance, internal transport, and intracellular mechanisms. Current knowledge of the iron proteins is summarized and this background is used in discussing the pathophysiology of iron deficiency and overload, together with the internal derangements such as sideroblastic anemia which form much of the clinical practice associated with disorders of iron metabolism. The therapeutic approach to these problems will be described.

Cricoid webs--incidence and follow-up study in Indian patients

A study was conducted to investigate the association of anaemia with dysphagia and cricoid webs in an adult Indian hospital population of 2,840 patients (1,200 males and 1,640 females). There were 150 cases (5.2%) of anaemia in the total population studied. One hundred and seventeen patients suffered from iron deficiency anaemia and only 33 from non-iron deficiency anaemia. Dysphagia was present in 15 patients (13%) of those with iron deficiency. Six (40%) of these cases of iron deficiency with dysphagia had cricoid webs. None of the cases with non-iron deficiency anaemia or the control population had either dysphagia or cricoid webs. Iron therapy improved four out of the six patients of iron deficiency with cricoid webs both subjectively and objectively.

Epidermolysis bullosa of the oesophagus with oesophageal wed formation

Marsden, R. A., Sambrook Gowar, F. J., MacDonald, A. F., and Main, R. A. (1974).Thorax, 29, 287-295. Epidermolysis bullosa of the oesophagus with oesophageal web formation. Four members of a family are described with epidermolysis bullosa dystrophica of probable autosomal recessive inheritance. They have shown the typical blistering of the skin and oral mucosa, usually present at birth, which occurs in this uncommon condition. Lesions occur after minor injury and heal slowly with scarring. Abnormalities of the nails and teeth are also present.

Oesophageal mucosal involvement can be a serious feature of this type of epidermolysis bullosa and usually manifests clinically as dysphagia and regurgitation of food and blood; oesophageal stenosis may ensue. Dysphagia was present in all four patients described in this study and regurgitation of an oesophageal cast occurred in one. Severe oesophageal stenosis occurred in two patients and minor narrowing and irregularity was present in the others. Treatment by oesophagoscopy and bouginage was carried out in the two patients with stenosis with some relief of dysphagia.

Oesophageal webs have rarely been reported in epidermolysis bullosa. In all four of our patients a postcricoid web was found. The presence of a smooth tongue in four patients and anaemia in two suggests the co-existence of the Paterson-Brown Kelly syndrome, although alternatively these webs may have resulted from the blistering and scarring process of epidermolysis bullosa.

The association between webs, iron and post-cricoid carcinoma

The association of iron deficiency anaemia, post-cricoid webs and carcinoma is controversial. The main findings in a recent study which re-examined this problem are presented here. It was shown that the majority of patients with a post-cricoid web have evidence of iron deficiency but that only about 10% of patients with iron deficiency develop post-cricoid webs. Factors which might be important in the pathogenesis of a post-cricoid web have been looked for and a few significant points noted. The main findings were an increased frequency of angular stomatitis and edentia, thyroid disease and thyroid cytoplasmic antibodies in patients with webs compared with patients with iron deficiency anaemia without a web.

Follow-up studies in patients with a post-cricoid web or Paterson-Kelly syndrome show an increased frequency of post-cricoid carcinoma ranging from 4 to 16% in different series and the association is even more striking in patients presenting with post-cricoid carcinoma. It is concluded that the available evidence confirms the association between iron deficiency, postcricoid webs and carcinoma but the mechanism of the production of these changes is not yet understood.

Benign strictures of the cervical oesophagus

Four patients with a stricture of the cervical oesophagus are described. The stricture was hard and fibrotic and usually involved at least 2 cm of the oesophagus; there was no obvious cause of these strictures. Its management is described, using a local skin flap to replace the stenosed segment. This condition does not appear to have been described before.

Dysphagia and oesophageal web in sideropenic anaemia

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