A 29-year-old man comes to the office due to difficulty swallowing for the past 2 years. Pork, chicken, and steak occasionally "get stuck" in his mid-chest seconds after he swallows. These episodes occur intermittently but with increasing frequency. Drinking water usually alleviates the symptoms, but the patient occasionally induces vomiting to eject the food. He has no trouble swallowing water, broth, or gelatin. The patient has no pain, cough, or nasal regurgitation after swallowing. He frequently plays football and takes ibuprofen to relieve aches and pains. He has seasonal allergies and takes antihistamines during the spring. Temperature is 37.3 C (99.1 F), blood pressure is 125/78 mm Hg, pulse is 76/min, and respirations are 12/min. BMI is 28 kg/m². Heart and lung sounds are unremarkable. The abdomen is soft, nontender, and nondistended. Which of the following is the most likely explanation for this patient's symptoms?

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11ec25c8_d87b_7851_bc81_371c76e0afa2_MD0003_00 Dysphagia (difficulty swallowing) is categorized as either oropharyngeal (difficulty initiating a swallow, with coughing/choking after eating) or esophageal (sensation of food stuck in the esophagus). Esophageal dysphagia to both solids and liquids indicates a motility disorder, with intermittent (eg, esophageal spasm) or progressive (eg, achalasia) symptoms depending on the underlying condition. Esophageal dysphagia to solids generally reflects mechanical obstruction; symptoms can also be progressive (eg, from solids to liquids), which suggests a developing stricture or cancer, or intermittent. Eosinophilic esophagitis (EoE), which most commonly affects younger men (age 20-30) and is associated with other atopic conditions (eg, asthma, eczema), classically presents with intermittent solid food dysphagia (often associated with eating meat) due to extensive eosinophilic infiltration of the mucosa. Other common manifestations include symptoms of refractory gastroesophageal reflux and chest/upper abdominal pain. If not recognized early, EoE can progress to fibrosis, leading to esophageal strictures that result in progressive dysphagia and food impaction. The endoscopic appearance of EoE includes furrowing; small, whitish exudates; and multiple stacked, ringlike esophageal indentations (trachealization of the esophagus). The diagnosis is confirmed with esophageal biopsy demonstrating ≥15 eosinophils per high-power field. Management includes dietary therapy (eg, allergen avoidance, elimination diet), proton pump inhibitors, and topical glucocorticoids (eg, fluticasone, budesonide). trachealization of the esophagus (Choice A) Achalasia results from the degeneration of myenteric plexuses in the esophagus, which prevents the lower esophageal sphincter from fully relaxing. Dysphagia is typically progressive (rather than intermittent) and involves both solids and liquids. (Choice C) Esophageal cancer typically causes a slowly progressive, rather than an intermittent, dysphagia. In addition, it is typically associated with unintended weight loss and is rare in patients in their 20s. (Choice D) Herpes esophagitis is more commonly associated with odynophagia, retrosternal chest pain, and fever than it is with dysphagia; typically occurs in immunocompromised patients (eg, HIV, organ transplant); and often causes concurrent oral ulcerations or herpes labialis. (Choice E) Myasthenia gravis can affect the bulbar muscles, which can lead to oropharyngeal rather than esophageal dysphagia. (Choice F) Ibuprofen is associated with pill esophagitis, which can result in dysphagia, but also typically causes retrosternal chest pain and severe odynophagia. Patients may be unable to swallow saliva due to pain. Educational objective: Eosinophilic esophagitis usually presents as intermittent solid food dysphagia and most commonly affects younger men with atopic conditions. Untreated disease can cause esophageal stricture and food impaction. Management includes dietary therapy (eg, allergen avoidance, elimination diet), proton pump inhibitors, and topical glucocorticoids (eg, fluticasone, budesonide).

A 29-Year-Old Man Comes to the Office Due to Difficulty