Your patient reports dysphagia.
Dysphagia can be grouped into four categories based on the site of dysfunction (oropharygeal vs esophageal) and the nature of the underlying issue (structural vs dysmotility).
Based on the HPI what do you suspect to be the etiology?
Esophageal Structural
Correct!
Esophageal Dysmotility
Incorrect. Try again!
Oropharyngeal Structural
Incorrect. Try again!
Oropharyngeal Dysmotility
Incorrect. Try again!
Build your differential diagnosis:
Which of these are in the top 3 of your differential diagnosis?
Eosinophilic esophagitis (EOE)
Good choice. The classic presentation of EOE is characterized by an adult male with asthma or other atopic comorbidities such as eczema or allergic rhinitis presenting with chronic intermittent dysphagia to solids. EOE can present with a food impaction, either due to severe mucosal inflammation or stenosis from longstanding disease leading to fibrosis and narrowing.
Esophageal Adenocarcinoma
Should be lower on the differential. The patient is a young non-smoker with longstanding symptoms, no red flag symptoms such as unintentional weight loss, and no history of uncontrolled GERD or family history of esophageal cancer. Moreover, his dysphagia is intermittent, not progressive, which is less suggestive of an intraluminal obstructing mass lesion.
Peptic stricture
Good choice. Reflux esophagitis may cause intermittent dysphagia to solids, though peptic stricture would likely cause progressive dysphagia.
Infectious Esophagitis
Should be lower on the differential. Infectious esophagitis (most commonly caused by candida, cytomegalovirus, or herpes simplex virus) is most often seen in immunocompromised patients, such as patients with human immunodeficiency virus or common variable immune deficiency, or in patients taking chemotherapy or immunosuppressants. Patients will often present with odynophagia and possibly fever.
Esophageal Ring/Web
Good choice. Esophageal rings and webs can cause intermittent dysphagia to solids in otherwise healthy adults and should be on the considered especially in younger adults presenting with dysphagia.
Plummer-Vinson Syndrome
Should be lower on the differential. This condition typically presents in older Caucasian women with a history of iron deficiency anemia.
Esophageal Crohn’s Disease
Should be lower on the differential. Bowel symptoms tend to present long before esophageal Crohn’s disease becomes apparent, and this patient has no symptoms of inflammatory bowel disease such as diarrhea, abdominal pain, or hematochezia.
Pill Esophagitis
Should be lower on the differential. This patient does not take any medications known to cause esophageal mucosal injury such as doxycycline or potassium chloride.
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Case 8 Index:
Introduction
Physical Exam
GI SIM 