What is the most likely diagnosis for a non-smoking, occasional alcohol user with no known comorbid illnesses, presenting with intermittent dysphagia (difficulty swallowing) to solids, characterized as a feeling of food stuck in the chest, without associated cough, vomiting, or weight loss?

Most Likely Diagnosis: Esophageal Web

The most likely diagnosis is esophageal web (Option C), given the intermittent dysphagia exclusively to solids, absence of progressive symptoms, and lack of alarm features in an otherwise healthy patient. 1

Clinical Reasoning Based on Symptom Pattern

Key Distinguishing Features

The patient's presentation of intermittent dysphagia to solids only is the critical diagnostic clue that points toward a mechanical obstruction rather than a motility disorder. 1

Esophageal dysphagia that begins with solids only is highly suggestive of a mechanical issue such as stricture, web, or tumor, whereas dysphagia for both solids and liquids from the outset suggests a motor problem like achalasia. 1

The intermittent nature argues strongly against progressive mechanical obstruction from malignancy and against consistent motility disorders. 2

Why Each Option Fits or Doesn't Fit

Option A: Diffuse Esophageal Spasm - UNLIKELY

• Diffuse esophageal spasm is a motility disorder that typically presents with dysphagia to both solids AND liquids simultaneously from onset, not solids alone. 1
• Patients with esophageal motility disorders usually report chest pain that can be severe and mimic cardiac pain, which this patient does not have. 3
• The absence of pain and the solid-only pattern make this diagnosis unlikely. 1

Option B: Achalasia - UNLIKELY

• Achalasia presents with dysphagia to both solids and liquids from the beginning, not progressive from solids to liquids. 1
• This is a key distinguishing feature: motor problems affect all consistencies equally from onset. 1
• The patient's solid-only dysphagia excludes achalasia as the primary diagnosis. 1

Option C: Esophageal Web - MOST LIKELY

• Esophageal webs cause intermittent mechanical obstruction that affects solids preferentially, exactly matching this patient's presentation. 1
• The intermittent nature occurs because the web creates a partial obstruction that may allow passage of food depending on bolus size and chewing adequacy. 3
• Webs are thin membranous structures that can cause the sensation of food "sticking" without causing progressive symptoms or weight loss. 1
• The absence of alarm features (no weight loss, no progressive worsening) supports a benign mechanical cause like a web rather than malignancy. 2

Option D: Scleroderma - UNLIKELY

• Scleroderma causes esophageal dysmotility affecting the smooth muscle of the distal esophagus, which would present with dysphagia to both solids and liquids. 1
• Patients with scleroderma typically have other systemic manifestations (skin changes, Raynaud's phenomenon, etc.), which this patient lacks. 3
• The solid-only pattern does not fit with scleroderma's pathophysiology. 1

Clinical Approach and Next Steps

Recommended Diagnostic Evaluation

• Biphasic esophagram (barium swallow) is the appropriate initial imaging study, with 96% sensitivity for structural esophageal abnormalities including webs. 2
• The ACR Appropriateness Criteria recommend fluoroscopic evaluation with both mucosal relief and double-contrast views to optimally visualize webs and other structural lesions. 1
• Esophagogastroduodenoscopy (EGD) can be performed as an adjunct or alternative, particularly if the barium study is inconclusive or if therapeutic intervention is needed. 3

Important Caveats

• Do not assume the location of pathology based on where the patient feels the obstruction—abnormalities of the distal esophagus or gastric cardia can cause referred sensation to the upper chest or throat. 1
• The absence of alarm features (weight loss, progressive symptoms, anemia) makes empiric acid suppression trial reasonable in some contexts, but given the clear mechanical pattern here, imaging should not be delayed. 2, 3
• The intermittent nature does not rule out serious pathology—even esophageal cancer can present with intermittent symptoms early on, though the lack of progression over time makes this less likely. 2

Red Flags That Would Change the Diagnosis

• Progressive dysphagia (solids progressing to liquids) would suggest malignancy or stricture requiring urgent evaluation. 2
• Weight loss or anemia would mandate immediate endoscopy to rule out esophageal cancer. 2
• Dysphagia to both solids and liquids from onset would point toward achalasia or other motility disorders. 1
• Associated chest pain would raise consideration of diffuse esophageal spasm or other motility disorders. 3