A 62-year-old male presents to an acute care clinic. He says that over the past 6 months, he has had difficulty swallowing, which has progressively gotten worse. In this time, he has lost 25 lbs. His past medical history is significant for hypertension and diabetes mellitus type 2. He has consumed up to 12 cans of beer per day for the last 25 years and has a 50-pack-per-year smoking history. Prior to the last 6 months, he had occasional heartburn for the last 20 years, but otherwise, no gastrointestinal complaints. Of the following, what is the most likely diagnosis?
A. Gastroesophageal reflux disease
B. Boerhaave’s syndrome
C. Esophageal adenocarcinoma
D. Achalasia
E. CREST syndrome
Based on the provided clinical presentation, the most likely diagnosis is:
C. Esophageal adenocarcinoma
Here’s the reasoning:
Esophageal adenocarcinoma typically presents with progressive dysphagia (difficulty swallowing), which has worsened over time in this patient. The weight loss of 25 lbs over 6 months is significant and raises concern for malignancy. Risk factors for esophageal adenocarcinoma include chronic gastroesophageal reflux disease (GERD), which this patient has had for 20 years, as well as heavy alcohol consumption and smoking, both of which are present in this case.
While gastroesophageal reflux disease (GERD) may initially present with heartburn and could potentially lead to complications such as Barrett’s esophagus, the rapid progression of symptoms and significant weight loss make esophageal adenocarcinoma a more likely diagnosis.
Boerhaave’s syndrome, a spontaneous rupture of the esophagus, typically presents with acute chest pain and vomiting after forceful vomiting or retching. This presentation does not match the gradual onset of symptoms described in the case.
Achalasia, characterized by impaired esophageal peristalsis and failure of the lower esophageal sphincter to relax, can lead to dysphagia but typically presents with a longer duration of symptoms and is less likely to cause significant weight loss.
CREST syndrome, also known as limited systemic sclerosis, primarily involves the skin and connective tissue and is not associated with the symptoms described in the case.
Given the patient’s history and clinical presentation, esophageal adenocarcinoma is the most likely diagnosis, and the patient should be referred for further evaluation, such as endoscopy, to confirm the diagnosis and initiate appropriate management.