226 THE LARYNX, BRONCHI AND OESOPHAGUS Any site may be affected, but due to the nature of the above conditions it is usually found in the middle or lower thirds of the oesophagus. SYMPTOMS. The symptoms are a gradually increasing dysphagia with some discomfort at the site of the stricture. On occasion the patient may present as an acute emergency with total dysphagia due to a bolus of meat becoming stuck in the stricture. If the condition is of long duration there will be weight loss. TREATMENT. In the non-malignant conditions, attempts should be made to alleviate the condition by dilatation. The initial dilatations are done via oesophagoscopy using Jackson bougies. Dilatations should be done until the stricture becomes tight. On no account should the stricture be dilated until it bleeds because this leads to more fibrous tissue formation. The dilatations are done at weekly or fortnightly intervals until the maximum lumen is achieved. At this point the patient should be taught to swallow a Hurst mercury bougie before meals to maintain the dilatation. If this regime is unsuccessful the stricture should be excised surgically and an end-to-end anastomosis performed. This is easier if the stricture is in the lower third than in the middle third where the results are unrewarding. PATERSON-BROWN KELLY SYNDROME AETIOLOGY. In the United States this is known as the Plummer-Vinson syndrome and it consists of dysphagia, hypochromic microcytic anaemia, angular stomatitis, glossitis and koilonychia. It is more common in females than in males, and also more common on the West coast of Britain than the East coast. The cause of the syndrome is unknown, but since there is an atrophy of all the mucous membranes of the alimentary tract an auto-immune basis must be presumed. SYMPTOMS. The dysphagia may be very marked, but it is not usually severe. The angular stomatitis, glossitis and koilonychia (Fig. 113) may be slight. The characteristic blood picture is a low haemoglobin and a hypochromic microcytic anaemia. All cases will have a low serum iron and a consequently high iron-binding capacity. A small, but significant, proportion of patients with this condition progress to the stage of postcricoid carcinoma. The relationship is not close enough to label the Paterson-Brown Kelly syndrome as a pre-malignant condition. A curious radiographic finding of unknown cause is a web at the postcricoid region (Fig. 114). This can often be seen at oesophagoscopy and may indeed be a firm diaphragm requiring dilatation, but sometimes a well-marked radiological web may not be visualized at oesophagoscopy. TREATMENT. Iron should be given orally at first until the haemoglobin is within normal limits. From then on, a check should be kept on the serum iron and the iron-binding capacity. When the haemoglobin has been restored to normal the serum iron will still be low and, due to absorption problems, may stay low in spite of oral iron administration. While the serum iron is low, dysphagia will continue, and so if oral iron fails to raise it to the normal level then the patient will require to be given parenteral iron. A check on the course of the disease during follow-up should always be by means of the serum ir rather than the haemoglobin.