What is Esophageal Webs and Rings?
The esophagus is a muscle-like tube that carries food from your throat to your stomach. There are several layers to this tube, the mucosa, the submucosa, and the muscularis propria. Occasionally, parts of these layers can form bumps, which are referred to as esophageal webs and rings. These bumps can partially block the tube. Most of the time, these bumps don’t cause any issues but sometimes, they can result in trouble swallowing solid foods.
These esophageal webs are often linked with a condition called Plummer-Vinson syndrome, which involves three main problems: low levels of iron in the blood (iron-deficiency anemia), trouble swallowing after the area of the throat that leads to the esophagus (postcricoid dysphagia), and the formation of these webs in the upper part of the esophagus. The difficulty swallowing usually occurs painlessly and slowly, first with solid foods and then with liquids after several years. Symptoms of difficulty swallowing only become noticeable when the diameter of the esophagus in the area of the web shrinks to less than about half an inch.
The difficulty in swallowing with Plummer-Vinson syndrome can usually be described in two levels. Level I involves occasional difficulty when consuming solid food, while Level II involves being able to swallow only semi-solid foods.
What Causes Esophageal Webs and Rings?
Esophageal webs and rings are a condition where abnormal, thin pieces of tissue form inside the esophagus. The exact cause remains debated. Several health conditions have been linked to esophageal webs and rings. Esophageal webs specifically have been linked to a condition known as Plummer-Vinson syndrome. This syndrome typically includes difficulty swallowing, anemia due to low iron levels, and the presence of esophageal webs. Other related conditions include Zenker’s diverticulum (a pouch that can form at the top part of the esophagus), epidermolysis bullosa (a group of rare skin conditions), pemphigus vulgaris (a serious skin blistering disease), and bullous pemphigoid (another blistering skin disease).
Esophageal rings, however, are most commonly linked to a hiatal hernia. This is where part of your stomach bulges up into your chest. Esophageal rings also have been associated with eosinophilic esophagitis, a condition where a certain type of white blood cell (eosinophil) builds up in the lining of the tube linking your mouth to your stomach (esophagus).
Risk Factors and Frequency for Esophageal Webs and Rings
Webs and rings in the esophagus often don’t show any symptoms, which makes it difficult to understand exactly how common they are. However, when people have an upper endoscopy (a procedure to look inside the esophagus) because they are having trouble swallowing, these webs and rings are found in about 5 to 15% of cases.
Signs and Symptoms of Esophageal Webs and Rings
Esophageal webs and rings often don’t cause any symptoms. However, if they protrude and narrow the esophagus, symptoms can arise. People with these conditions usually experience problems swallowing solid food. In more severe cases, someone may not be able to swallow food or even their saliva. Plummer-Vinson syndrome, which comprises difficulty swallowing, esophageal webs, and iron deficiency anemia, also presents with these symptoms.
Physical symptoms alone usually can’t identify esophageal webs and rings, but a detailed physical exam may uncover an associated condition. For example, skin symptoms of iron deficiency anemia, such as misshapen nails (koilonychia), inflamed tongue (glossitis), and cracked lips (cheilosis), can indicate Plummer-Vinson syndrome. Blistering skin conditions like epidermolysis bullosa or pemphigus vulgaris may also be seen during a skin examination.
Testing for Esophageal Webs and Rings
If you’re having trouble swallowing (known as dysphagia), lab tests often aren’t that helpful if your doctor suspects the cause is esophageal webs or rings. Esophageal webs or rings are thin layers of tissue that form a ring or line in the esophagus, which can cause difficulty when swallowing. Your doctor may ask for a complete blood test and check your iron levels to see if they are normal.
That said, the best way to know for sure both if you have dysphagia and what’s causing it, is through specific procedures – a barium swallow test or an upper endoscopy.
A barium swallow test is really good for finding what’s causing blockages in your esophagus. In this test, you swallow a substance called barium that shows up on X-rays. This way, your doctor can get a clear image of your esophagus and see if there are esophageal webs, rings, narrowing (also known as strictures), tumors, or even outside pressure on the esophagus.
An upper endoscopy (also known as esophagogastroduodenoscopy or EGD) is generally needed to confirm a diagnosis. In an EGD, a small flexible tube with a light and a camera on the end is inserted down your throat to take a closer look inside your esophagus. Esophageal webs will show up as thin layers that don’t cover all the way around the inside of your esophagus. Esophageal rings also appear thin, but unlike webs, they go all the way around your esophagus. An EGD can also spot other causes of dysphagia like narrowing, tumors, and polyps. If there’s a chance the problem could be cancerous, an EGD lets your doctor take a small sample of tissue (biopsy) for further testing. An EGD can also spot related conditions like eosinophilic esophagitis (when white blood cells build up in the lining of your esophagus, causing it to become inflamed), hiatal hernia (when part of your stomach pushes up into your chest through a hole in your diaphragm), and Zenker’s diverticulum (a pouch that forms in your throat, right above your esophagus).
Treatment Options for Esophageal Webs and Rings
When it comes to relieving symptoms from esophageal webs and rings, the primary treatment option is a procedure known as endoscopic esophageal dilatation. This procedure is used to widen the esophagus – the tube connecting your mouth to your stomach – which can alleviate difficulty in swallowing and prevent the problem from recurring. It’s important to mention that sometimes esophageal webs can tear during this procedure. However, it can still be performed even if a web has somewhat torn.
It’s necessary to take a biopsy of esophageal rings before dilatation can be performed to rule out a condition called eosinophilic esophagitis, which is a chronic disease where the esophagus becomes filled with a type of white blood cell called eosinophils. After esophageal rings have been dilated, the patient may need to take a type of medication called a proton pump inhibitor (PPI). This is because esophageal rings are often found close to the gastroesophageal junction, where the esophagus meets the stomach. These medications reduce the production of stomach acid, which might help with symptoms.
It’s important to note that esophageal dilatation is generally a safe and effective treatment, with a low risk of complications. However, one issue is that sometimes, particularly for esophageal rings, the problem can come back after treatment. Studies have shown that using a PPI medication can help reduce this risk of recurrence.
If esophageal rings keep causing symptoms and come back even after multiple dilatations, then other treatments options are available. These can include a procedure where a small incision is made in the ring using an electrically heated instrument (electrocautery), or with a laser (laser division).
What else can Esophageal Webs and Rings be?
When trying to diagnose esophageal webs and rings, doctors also have to consider other conditions that can cause similar symptoms, such as problems swallowing. Useful ways to identify these other conditions might include a patient’s medical history and specific evaluations called ‘barium swallow’ and ‘EGD’. These tests can help doctors identify conditions that might look like webs and rings, but are actually different problems.
For example, a condition called achalasia often shows similar difficulties in swallowing both solid and liquid foods. From a barium swallow test, achalasia might show an unusual ‘bird-beak’ appearance, which is typically seen as a widening at the end of the esophagus.
Similarly, esophageal strictures, legnthy narrowings in the esophagus, can cause the same issue of difficult swallowing. Compared to webs and rings, they generally look longer in a barium swallow test and have tapered ends.
What to expect with Esophageal Webs and Rings
The outlook for people with esophageal webs and rings is generally very good because most people don’t experience any symptoms. When symptoms do appear, they can be treated successfully with a procedure called esophageal dilatation, which involves widening the esophagus. This procedure is considered both safe and effective.
The main concern with this treatment is that the esophageal rings can become narrow again after dilatation. To lower the risk of this happening, doctors often prescribe a type of medication known as a PPI (proton pump inhibitor) after the dilatation procedure.
Possible Complications When Diagnosed with Esophageal Webs and Rings
Most people with esophageal webs and rings do not experience any symptoms. Problems only occur when these webs and rings stick out into the open space of the esophagus causing it to narrow. If the narrowing is severe, patients may have difficulty swallowing food or even saliva which is a condition called dysphagia. Sometimes, it can even lead to a case where food gets stuck in the esophagus which is known as food impaction.
Common Issues:
- No symptoms in most cases
- Difficulty swallowing (Dysphagia) when rings or webs protrude into the esophagus
- Severe narrowing can lead to food getting stuck (Food Impaction)
- In extreme cases, inability to swallow even saliva
Preventing Esophageal Webs and Rings
Patients should be informed about the harmless nature of their condition. This means their condition is not generally serious or life-threatening. Additionally, they should be taught about warning signs that could signal that a hidden health condition is getting worse. These signs can involve a loss of interest in food, losing weight, or noticing blood in their stools.
Patients should also be advised to take their prescribed medicines, specifically Proton Pump Inhibitors (PPI), which reduce stomach acid. Following the correct dosage can help lower the chance of their condition becoming severe again after it has been treated.
