S4220 Cutting Weight, but Losing Iron: Post-Gastric Bypass Plummer-Vinson Syndrome

Introduction: Plummer-Vinson syndrome (PVS) is a rare disease characterized by the triad of iron-deficiency anemia, dysphagia and esophageal webs. The condition was more commonly seen in the earlier half of the 20th century, particularly in middle-aged Scandinavian women with a rapid decline attributable to an improvement in nutritional supplementation as well as the widespread fortification of flour with iron. Our case is particularly noteworthy, not only for its rare prevalence but also for its occurrence in a patient of African American descent. Case Description/Methods: A 55-year-old African American woman with a history of Roux-en-Y gastric bypass surgery presented to the emergency department complaints of chest pain, shortness of breath and dysphagia to solids. She endorsed weight loss of over 200 lbs since her gastric bypass surgery 18 years prior. Laboratory findings were remarkable for severe Iron Deficiency. An endoscopy showed the classic appearance of a proximal esophageal web with some other milder webs in the mid esophagus consistent with PVS. Gastric bypass anatomy was seen with an intact gastric pouch and a gastric jejunal anastomosis. Colonoscopy findings were unremarkable. She was subsequently discharged with instructions to begin oral iron supplementation. Discussion: In recent literature there have only been 3 other reported cases of PVS after gastric bypass surgery. Iron deficiency anemia is a common post-procedural development due to reduced iron absorption, as the surgery bypasses the duodenum—the primary site of iron uptake. The exact pathogenesis of Plummer-Vinson syndrome remains largely unknown, though several hypotheses have been proposed. One theory suggests that dysfunction in iron-dependent oxidative enzymes results in myasthenic changes in the swallowing muscles, esophageal mucosal atrophy, and subsequent web formation as an epithelial complication. It is believed that persistent epithelial injury caused by iron deficiency leads to mucosal atrophy and pharyngeal muscle degradation, ultimately contributing to the development of esophageal webs. They can be seen on barium swallow or as in our case via direct visualization on endoscopy. The initiation of iron supplementation addresses the underlying deficiency, with patients having excellent outcomes and resolution of symptoms. This case highlights the critical importance of vigilant long-term follow-up after gastric bypass surgery, as serious complications can arise even many years postoperatively.