The most likely diagnosis is eosinophilic esophagitis (EoE). This patient has the classic presentation of EoE, which occurs in a young man with solid-food dysphagia that requires endoscopy for removal. EoE is the result of eosinophil cell infiltration of the esophageal squamous mucosa. The incidence of EoE is thought to be increasing, and it seems to parallel the increasing incidence of allergic disease and asthma. Asthma and systemic and seasonal allergies have significant prevalence in adults with EoE. EoE is diagnosed by the finding of greater than 15 eosinophils/hpf on esophageal endoscopic biopsy and by exclusion of GERD. GERD must be excluded because it can also cause esophageal eosinophilic infiltration. This can be done with a therapeutic trial of a proton pump inhibitor (PPI) for 8 weeks. Clinical response to PPI therapy should be assessed based on improvement of clinical symptoms and even repeating the upper endoscopy with biopsies to demonstrate mucosal healing. Endoscopy often reveals characteristic findings of EoE such as rings, longitudinal furrows, and sometimes strictures. Medical therapy consists of swallowed aerosolized topical glucocorticoids (fluticasone or budesonide).

Achalasia is also characterized by dysphagia; however, endoscopic findings of achalasia would include a dilated esophagus with a tight gastroesophageal junction, where the lower esophageal sphincter is located. These endoscopic findings are not present in this patient.

Barrett esophagus (BE) is the result of chronic acid reflux, but it is usually not associated with dysphagia, especially in a young person. The diagnosis of BE is suggested by endoscopic findings of salmon-colored mucosa at the gastroesophageal junction compared with the normal pearl-colored squamous mucosa and is confirmed histologically by the presence of specialized intestinal metaplasia with acid-mucin–containing goblet cells.

Diffuse esophageal spasm is usually characterized by dysphagia or chest pain but not food impaction. Manometry shows intermittent, high-amplitude, simultaneous, nonperistaltic contractions in response to swallowing. Findings of a “corkscrew esophagus” (caused by multiple simultaneous contractions) on barium swallow are typical of diffuse esophageal spasm. Longitudinal rings or furrows are not seen on endoscopic examination.