Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 25-year-old man is evaluated for a 5-year history of slowly progressive solid-food dysphagia that is accompanied by a sensation of food sticking in his lower retrosternal area. He has compensated by modifying his diet and avoiding fibrous meats. He has not lost weight, and he has not had trouble drinking liquids. He has had episodes of food impaction that he manages by inducing vomiting. He has had no difficulty initiating a swallow and has not had chest pain, odynophagia, reflux symptoms, or aspiration of food while swallowing. He has seasonal allergies that are treated with antihistamines and asthma that is treated with inhaled albuterol.

Physical examination is normal.

Which of the following is the most likely diagnosis?

A: Achalasia
B: Eosinophilic esophagitis
C: Esophageal candidiasis
D: Esophageal malignancy
E: Oropharyngeal dysphagia

MKSAP Answer and Critique

The correct answer is B: Eosinophilic esophagitis.

Slowly progressive solid-food dysphagia in a young man who has allergic diseases is likely due to eosinophilic esophagitis. This patient’s history (location of symptoms, absence of aspiration, and intact initiation of swallows) suggests esophageal dysphagia rather than oropharyngeal dysphagia. Patients with eosinophilic esophagitis can present with symptoms similar to those of gastroesophageal reflux disease, but young adults frequently present with extreme dysphagia and food impaction. There is a strong male predominance. The diagnosis is made by endoscopy, with mucosal biopsies showing marked infiltration with eosinophils (>15 eosinophils/hpf), and the exclusion of gastroesophageal reflux by either ambulatory pH testing or by nonresponse to a therapeutic trial of proton-pump inhibitors for 6 weeks. Macroscopic findings at endoscopy are nonspecific and insensitive but proximal strictures are most consistently observed. Other findings include mucosal rings (sometimes multiple), mucosal furrowing, white specks, and mucosal friability. Some patients have evidence of a motility disorder, suggesting involvement of the muscular layers. Treatment with swallowed aerosolized topical corticosteroid preparations or systemic corticosteroids provides excellent short-term relief.

Slowly progressive solid-food dysphagia in the absence of dysphagia to liquids is more suggestive of an intraluminal mechanical cause (such as a stricture or ring) than a motility disturbance like achalasia, which usually presents with dysphagia to both solids and liquids and may be associated with chest pain and regurgitation.

Esophageal infections in immunocompetent persons are most common in patients who use swallowed aerosolized corticosteroids or in patients with disorders that cause stasis of esophageal contents. Candida albicans is the most common organism causing esophagitis in immunocompetent patients. Although esophageal candidiasis can present with dysphagia, the chronic nature of this patient’s symptoms (lasting for years) and the absence of oropharyngeal candidiasis make esophageal candidiasis an unlikely cause.

Malignancy is an unlikely diagnosis because of this patient’s young age, long duration of symptoms, and lack of weight loss despite prolonged symptoms.

Oropharyngeal dysphagia is characterized by difficulty in the initial phase of swallowing, in which the bolus is formed in the mouth and is transferred from the mouth through the pharynx to the esophagus. This patient is not experiencing difficulty swallowing.

Key Point

• Slowly progressive solid-food dysphagia in a young man who has allergic diseases is likely due to eosinophilic esophagitis.

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