Peptic Stricture is the Most Likely Diagnosis
The most likely diagnosis is peptic stricture (Option D), given the slow progressive dysphagia, prolonged history of retrosternal discomfort requiring H2 blockers, absence of weight loss, and normal hemoglobin level. 1, 2
Clinical Reasoning
Key Diagnostic Features Supporting Peptic Stricture
Progressive dysphagia pattern: Peptic strictures characteristically present with slowly progressive dysphagia to solids over months to years, which matches this patient's presentation 1, 2
Longstanding reflux symptoms: The year-long history of retrosternal discomfort requiring H2 blockers indicates chronic gastroesophageal reflux disease (GERD), the primary cause of peptic strictures 2, 3
Absence of weight loss: Peptic strictures typically develop gradually, allowing patients to adapt their diet without significant weight loss, unlike malignancy 1
Normal hemoglobin: The hemoglobin of 13.3 g/dL excludes significant chronic bleeding, making esophageal cancer less likely 4
Why Other Diagnoses Are Less Likely
Esophageal Cancer (Option E) is unlikely because:
- Progressive dysphagia from malignancy typically occurs over weeks to months (not years) and is associated with weight loss 4
- Anemia from chronic occult bleeding is a common presenting feature of esophageal cancer, which this patient lacks 4
- The patient's age and symptom duration favor benign disease 5
Plummer-Vinson Syndrome (Option B) is excluded by:
- Normal hemoglobin level (this syndrome requires iron deficiency anemia as a diagnostic criterion) 6
- Absence of other features like glossitis or koilonychia
Pharyngeal Pouch (Option C) presents differently with:
- Regurgitation of undigested food
- Halitosis and gurgling in the neck
- Not typically associated with chronic reflux symptoms 5
Foreign Body (Option A) causes:
- Acute onset dysphagia, not slow progression over months
- Usually a clear history of ingestion 5
Diagnostic Approach
Immediate Next Steps
Upper endoscopy with biopsies is mandatory to confirm peptic stricture and exclude malignancy, as both can present with dysphagia 6, 1, 2
Barium esophagram can be performed first if the patient tolerates adequate oral intake, with 95% sensitivity for detecting strictures 6
Obtain minimum 6 biopsies during endoscopy to exclude malignancy, as peptic strictures can harbor dysplasia or cancer 4, 1
Critical Pitfall to Avoid
Never assume benign disease based on longstanding reflux history alone—approximately 10% of patients with chronic GERD develop peptic strictures, but malignancy must always be excluded with tissue diagnosis 2. The British Society of Gastroenterology emphasizes that patients over 45 years with recent onset or change in dyspeptic symptoms require early endoscopy to exclude gastric cancer 5.
Management Considerations
Once peptic stricture is confirmed:
- Proton pump inhibitors (PPIs) are superior to H2 blockers for healing esophagitis and reducing dilation requirements 3
- Healing coexistent esophagitis is essential for improving dysphagia and decreasing the need for repeated dilations 1, 3
- Endoscopic dilation combined with aggressive acid suppression provides optimal outcomes 2, 3