ABIM Exam Review Practice Question of the Week: 24-year-old female with intermittent dysphagia
24-year-old female presents with intermittent dysphagia, usually after she eats bread or steak. She says she has to have regurgitation of symptoms to feel relief. She denies dysphagia to liquids. Which of the following is the likely diagnosis?
A. Systemic sclerosis B. Schatzki ring C. Achalasia D. Diffuse esophageal spasm E. Esophageal cancer
ABIM Exam Review Question Explanation
Young patients who have intermittent dysphagia to solid foods such as bread or meats are likely to have Choice B (Schatzki or lower esophageal ring). Symptoms often arise with steak consumption earning this diagnosis the nickname “Steakhouse syndrome.” This condition is associated with hiatal hernia. Even though there is no evidence that reflux plays a role in this condition’s pathogenesis, after dilatation, patients are placed on proton pump inhibitors. On a barium swallow (which is the initial test to order), the ring needs to be less than or equal to 13mm to cause symptoms.
Let’s go through the other answer choices:
- Choice A (Systemic sclerosis or scleroderma) is incorrect as it is a motility problem that is expected to cause dysphagia to both solids and liquids. If the patient had scleroderma, connective tissue disease or Raynaud’s phenomenon may also be seen. Scleroderma is associated with chronic heartburn.
- Choice C (Achalasia) is another motility problem and we would, therefore, expect dysphagia to solids and liquids concurrently. Patients with achalasia will also have regurgitation and can have relief of symptoms if they raise their arms over their head. Unlike Schatzki rings, it is progressive.
- Choice D (Diffuse esophageal spasm) would have dysphagia to solids and liquids, as well as chest discomfort, especially after drinking cold beverages or carbonated drinks.
- Choice E (Esophageal cancer) is not likely as the patient would usually have a long-standing history of smoking or uncontrolled reflux that can lead to squamous cell carcinoma or adenocarcinoma, respectively. Also in the history, you would expect unintentional weight loss in a patient older than 50 years.
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