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The correct answer is B) Stricture. “Common things are common” – the gentleman does not give a history consistent with foreign body ingestion, and the remaining choices, though plausible, are rare. This question was harder than average because of the extraneous information and labs provided (I did not trim/edit the details of the original case).
Benign esophageal stricture is by far the most likely explanation for this patient’s dysphagia – a complication in up to 10% of patients with GERD, strictures are a common reason for referral to a gastroenterologist. They are confirmed by endoscopy & their benign nature is ensured through biopsy performed at the time of examination; balloon dilation of the strictured portion of the esophagus can also be performed at this time.
A) Angioedema (swelling of the dermis & subcutaneous tissue) is incorrect for several reasons. It is often the result of a drug reaction or allergy, and is a medical emergency because the patient’s airway can become compromised, requiring intubation. One would not expect difficulty swallowing over a period of days, and the patient’s head & neck exam are normal. ACE inhibitors (e.g. lisinopril) are one of the drug classes associated with angioedema (and African Americans are actually more susceptible to this reaction).
C) Cancer is another worrisome possibility that must be ruled out in this patient. Specifically, his smoking puts him at increased risk for squamous cell carcinoma of the esophagus. Cancer develops over time and is expected to cause progressive difficulty swallowing solids, followed by liquids (as the lumen of the esophagus grows more narrow). One would also expect to see weight loss, constitutional symptoms, and other hallmarks such as a hoarse/raspy voice (secondary to impingement of the recurrent laryngeal nerve). A more subtle, and certainly not definitive, clue is the character of the x-ray – instead of the neat narrowing shown, there would be irregular narrowing and compensatory dilation of the proximal esophagus (pseudoachalasia).
D) Achalasia is an uncommon disorder of esophageal dysmotility (specifically, the lower esophageal sphincter fails to relax), resulting in massive dilatation of the proximal esophagus; it can be caused by specific diseases (e.g. Chagas disease), but the true etiology of most achalasia is unknown. Barium swallow has a diagnostic accuracy of 95%, and shows the characteristic “bird’s beak” appearance of the esophagus.
E) Foreign body is incorrect based on history and negative radiographic studies, but should certainly be considered in the initial differential.
F) Eosinophilic esophagitis may present with dysphagia (#1 presenting complaint), but is typically diagnosed in young men between 20-30 years of age, typically those with a history of asthma, dermatitis, allergic rhinitis, or other atopic syndromes. Characteristic “furrowing” can be seen on endoscopic examination (or even barium swallow), though strictures may develop, and biopsy showing eosinophilic infiltration (>15/hpf) is required for diagnosis.
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