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Case Report
Figure 1 · Esophageal webs and duodenal mucosa
Figure 2 · Duodenal histology
Experienced teaching points
Clinical Pearls
01Plummer-Vinson belongs on the differential when dysphagia meets iron-deficiency anemia, especially with proximal esophageal webs.
02Celiac disease can be the iron-loss driver. Check tTG and biopsy the duodenum even when the presenting problem is a web.
03Endoscopic dilation is effective for symptomatic webs that block a standard endoscope.
04When webs, varices, and celiac sit in one case, look for the shared systemic thread before treating each finding in isolation.
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Final Diagnosis
Plummer-Vinson syndrome associated with celiac disease, treated with endoscopic dilation and medical management of esophageal varices.
Clinical History
A 48-year-old woman presented with one month of dysphagia and no weight loss. Physical examination was unremarkable. Hemoglobin was 8.9 g/dL, MCV 78, transferrin low, and iron 18. Tissue transglutaminase was 10 times the upper limit of normal.
Endoscopic Findings
- Esophageal webs that could not be traversed with a standard endoscope.
- Esophageal varices.
- Duodenal biopsies showed total mucosal atrophy.
Endoscopic Technique
- A standard endoscope could not pass the webs.
- Careful endoscopic dilation was performed to traverse them.
- Variceal banding was not possible because the webs blocked access.
- At one-month follow-up the varices were smaller and banding was not required.
Discussion
Mechanism. This is classic Plummer-Vinson: esophageal webs plus iron-deficiency anemia. The authors propose that chronic iron deficiency, driven or worsened by celiac disease, produced the webs. That matches the usual pathophysiology of Plummer-Vinson. The celiac-plus-PVS pairing is still thinly described.
What the scope shows. Tight webs blocked a standard endoscope, so dilation came first. Varices were seen but could not be banded through the webs. Duodenal biopsies showed total mucosal atrophy, matching a tTG ten times the upper limit of normal. One month later the varices had shrunk on medical therapy and banding was unnecessary.
Why it matters clinically. Treat the web, then keep looking. Iron deficiency is the link, and celiac can be the source. The varices improved medically. A direct causal tie from PVS or celiac to the varices is not clear from this case, so do not force one. When several GI findings land in the same patient, hunt for the shared driver.
References
- Hoffman RM, Jaffe PE. Plummer-Vinson syndrome. A case report and review of the literature. Arch Intern Med. 1995;155(18):2008-2011.
- Dickey W, Cullen G. The aetiology of iron deficiency in patients with celiac disease. Scand J Gastroenterol. 1999;34(12):1203-1206.
- Genta RM, Gist TL, Hammer RA. Esophageal webs: an unusual cause of dysphagia. Am J Gastroenterol. 1980;73(4):307-310.
For your teaching file
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