A 51-year-old man comes to the physician with difficulty swallowing solids but not liquids. His medical history is significant for gastroesophageal reflux disease for the last 12 years. He underwent endoscopy and was diagnosed with Barrett's esophagus 6 months ago. His heartburn resolved 3 months after this diagnosis. The patient's vital signs are within normal limits. His body mass index is 38 kg/m². Barium swallow now shows an area of symmetric, circumferential narrowing affecting the distal esophagus. Which of the following best explains this finding?

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This patient's presentation - chronic gastroesophageal reflux with new dysphagia and symmetric lower esophageal narrowing - suggests esophageal (peptic) stricture. Chronic gastroesophageal reflux disease (GERD) predisposes to Barrett's esophagus (intestinal metaplasia of the lower esophagus) and esophageal strictures. Both conditions are consequences of the body's reparative response to chronic gastric acid exposure and can occur simultaneously. Benign strictures affect 5%-15% of patients with GERD. Other causes of peptic strictures include radiation, systemic sclerosis, and caustic ingestions. Strictures typically cause slowly progressive dysphagia to solid foods without anorexia or weight loss. As they progress, they can actually block reflux, leading to improvement of heartburn symptoms (as seen in this patient). Strictures tend to appear as symmetric, circumferential narrowing on barium swallow. Nonetheless, in any case of stricture in the setting of Barrett's esophagus, biopsy is necessary to rule out adenocarcinoma. This is usually accomplished via endoscopy which may be diagnostic and therapeutic (dilation is performed if no malignancy is detected). (Choice A) Achalasia is an esophageal motility disorder that presents with dysphagia (both solids and liquids) and regurgitation of undigested food or saliva. Barium swallow typically shows aperistalsis, poor emptying of barium, dilation of the proximal esophagus (caused by retention of food), and narrowing in a "bird beak" pattern at the gastroesophageal junction. Achalasia (Choice B) Adenocarcinoma typically occurs in patients who have had GERD symptoms for >20 years. Early symptoms of esophageal cancer are subtle and include retrosternal discomfort, mild dysphagia to solid foods, and/or a burning sensation. Barium swallow generally shows asymmetric narrowing of the esophageal lumen. (Choice D) A hiatal hernia is a protrusion of the stomach above the diaphragm. These patients may have GERD and are also at risk for Barrett's esophagus, peptic strictures, and adenocarcinoma. Barium swallow shows gastric folds protruding above the diaphragm. (Choice E) Vascular rings are uncommon congenital anomalies in which aortic arch vessels encircle the trachea and/or esophagus. Patients may present in infancy with symptoms of airway obstruction, though some patients do not present until adulthood. In adult cases, dysphagia is usually the presenting complaint. There is not a strong association with GERD or Barrett's esophagus. Educational objective: Gastroesophageal reflux disease (GERD) predisposes to Barrett's esophagus, erosive esophagitis, and esophageal (peptic) stricture formation. Peptic strictures cause symmetric and circumferential narrowing of the involved esophagus with dysphagia for solids but typically no weight loss. Other causes of peptic strictures include radiation, systemic sclerosis, and caustic ingestions. References: Incidence of adenocarcinoma among patients with Barrett's esophagus. (http://www.ncbi.nlm.nih.gov/pubmed/21995385) Predictive value of symptoms and demographics in diagnosing malignancy or peptic stricture. (http://www.ncbi.nlm.nih.gov/pubmed/22969199)

A 51-Year-Old Man Comes to the Physician with Difficulty Swallowing