Most Likely Diagnosis: Esophageal Cancer
The most likely diagnosis is D. Cancer of the esophagus (esophageal carcinoma), given the 9-month progressive dysphagia for both solids and liquids, central chest discomfort, nocturnal cough, and anemia. 1
Clinical Reasoning
Key Diagnostic Features Supporting Esophageal Cancer
Progressive dysphagia for both solids AND liquids over 9 months is highly characteristic of esophageal malignancy, as the tumor progressively narrows the esophageal lumen 1
Anemia (Hb 11.8 g/L) indicates chronic occult bleeding from the tumor, which is a common presenting feature of esophageal cancer even when clinical examination appears unremarkable 1
Central chest discomfort reflects tumor involvement causing retrosternal pain, a typical symptom of esophageal malignancy 1
Nocturnal cough suggests either aspiration from esophageal obstruction or potential laryngeal nerve involvement by the tumor 1
Unremarkable clinical examination is typical even with locally advanced esophageal cancer, as physical findings often only appear with metastatic disease 1
Why Other Diagnoses Are Less Likely
Achalasia (Option A): While achalasia causes dysphagia for both solids and liquids, it typically presents with regurgitation of undigested food and does not cause anemia or the progressive worsening pattern seen here over 9 months 1
Esophageal web (Option B): Esophageal webs (Plummer-Vinson syndrome) do present with dysphagia and iron-deficiency anemia, but they typically cause dysphagia primarily for solids, occur in the cervical esophagus, and present in middle-aged women with more severe anemia 2, 3, 4
Pharyngeal pouch (Option C): Pharyngeal pouches cause oropharyngeal dysphagia with regurgitation of undigested food, halitosis, and gurgling sounds—none of which are described here 1
Immediate Next Steps
Upper endoscopy with multiple biopsies (minimum 6 biopsies) is mandatory to confirm the diagnosis, as the friable mucosa of esophageal cancer requires adequate tissue sampling 1
Critical Documentation at Endoscopy
- Exact tumor location relative to gastroesophageal junction 1
- Distance from incisors 1
- Tumor length and circumferential involvement 1
- Presence of obstruction 1
- Any Barrett's esophagus or dysplasia 1
Staging After Diagnosis
Once malignancy is confirmed, staging requires 1:
- Spiral CT of thorax and abdomen to assess for metastatic disease 1
- Endoscopic ultrasound to determine depth of invasion and nodal involvement in absence of metastases 1
- Additional modalities (MRI, bronchoscopy, laparoscopy) as clinically indicated 1
Critical Pitfalls to Avoid
Do not delay endoscopy with empiric acid suppression therapy in patients presenting with alarm symptoms (dysphagia, weight loss, anemia), as this can mask underlying malignancy and delay diagnosis 1
Do not assume benign disease in patients with longstanding reflux or dysphagia until endoscopy with biopsy excludes malignancy 1
Recognize that anemia may be the only laboratory abnormality in esophageal cancer, as other routine labs are often normal 1