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), as this patient presents with the classic triad: intermittent dysphagia to solids only, absence of alarm features (no weight loss, cough, or vomiting), and a non-progressive course. 1

Diagnostic Reasoning

Why Esophageal Web is Most Likely

• Dysphagia pattern is pathognomonic for mechanical obstruction: Esophageal dysphagia that begins with solids only is highly suggestive of a mechanical issue such as stricture, web, or tumor, rather than a motor problem 1

• Intermittent nature supports benign mechanical cause: The intermittent, non-progressive pattern argues strongly against malignancy or stricture, which would cause progressive worsening 2

• Absence of alarm features confirms benign etiology: The lack of weight loss, progressive worsening, or other red flags supports a benign mechanical cause like a web rather than malignancy 1

• "Food stuck in chest" sensation is characteristic: This specific symptom description aligns with mechanical obstruction at the level of the esophagus 3

Why Other Options Are Less Likely

Achalasia (Option B) is excluded by the clinical pattern:

• Achalasia presents with dysphagia to both solids and liquids from the outset, not solids alone 1, 2
• This is a fundamental distinguishing feature: dysphagia for both solids and liquids simultaneously from onset suggests a motility disorder like achalasia 2
• The patient's solid-only dysphagia rules out this motor disorder 1

Diffuse esophageal spasm (Option A) is unlikely:

• Esophageal motility disorders typically cause dysphagia to both solids and liquids, not solids alone 1
• Spasm usually presents with chest pain as a prominent feature, which is not described here 3

Scleroderma (Option D) is excluded:

• The patient has "no known comorbid illness," making systemic sclerosis extremely unlikely 3
• Scleroderma-related dysphagia would also affect both solids and liquids due to impaired esophageal motility 3

Recommended Next Steps

Initial diagnostic evaluation should include:

• Biphasic esophagram (barium swallow) as the appropriate initial imaging study, with 96% sensitivity for structural esophageal abnormalities including webs 1
• Fluoroscopic evaluation with both mucosal relief and double-contrast views to optimally visualize webs and other structural lesions 1

Critical Pitfalls to Avoid

• Do not assume location equals pathology: Obstructive symptoms that seem to originate in the throat or neck may actually be caused by distal esophageal lesions 3
• Watch for progression: Progressive dysphagia (solids progressing to liquids) would suggest malignancy or stricture requiring urgent evaluation 1
• Monitor for alarm features: Weight loss or anemia would mandate immediate endoscopy to rule out esophageal cancer 1