Hotobhaga
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3) A 62-year-old social worker complains of increasing difficulty with swallowing. She has had trouble with solid foods and senses a discomfort in the mid-lower chest after eating meats or dry bread. She has not lost any weight and denies any other medical problems. There is no family history of gastrointestinal malignancy. The physical examination is unremarkable. Which of the following would be the most appropriate next step in the evaluation of this patient's symptoms?
A. Barium esophagram
B. Chest x-ray
C. CT scan of the chest
D. Esophagoscopy
E. 24-hour pH monitor
Explanation:
The correct answer is
D. This patient is presenting with symptoms of a peptic stricture after many years of gastroesophageal reflux disease (GERD) symptoms. An endoscopy not only will allow evaluation of the stricture but will also allow biopsy to ensure that it is of a benign nature. Furthermore, it would allow dilatation of the stricture using an endoscopic-guided balloon to relieve the patient's symptoms.
A barium esophagram (choice A) would demonstrate the typical smooth tapering nature of a peptic stricture, distinguishing it from the irregular, ulcerated, mass-like stricture seen in patients with esophageal carcinoma. However, it would not conclusively make this distinction and would require a follow-up endoscopy with biopsy anyway.
A chest x-ray (choice B) is not of specific diagnostic value in patients who are undergoing evaluation for dysphagia.
A CT scan of the chest (choice C) is not very useful in determining intraluminal esophageal lesions. CT is used for patients with suspected malignant strictures to evaluate the paraesophageal regions and assess for the possibility of local spread.
A 24-hour pH monitor (choice E) is useful to demonstrate that there is acid reflux, which is not in question with this patient with the longstanding history of typical symptoms
but is it not true that you need a esophagogram before any esophagoscopy. uw says so...
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| ssrpk
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are u sure UW says that, does it say for which disease, because given the age of patient esophageal carcinoma must be high on the differential and even with completely normal esophagogram, esophagoscopy would still be indicated to completely rule out tumor...
may be someone can better comment on this, but to me D seem appropriate
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| young_doc
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UW does indeed say that in difficulty swalling, do Barium, followed by Endoscope.
BUT:
Within the same explanation, UW ALSO SAYS THAT if it's painful, if there's loss of weight, or if you're suspecting an obstructive lesion, then you should do an Endoscope first. Clearly in this case it's not just difficulty swallowing, as she also senses discomfort in the chest. A obstructive lesion should therefore be in you index of suspicion, and so do Endoscopy first.
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| ssrpk
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thanks for explaining young-doc
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| sprint123
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 According to UW----Barium swallow is indicated FIRST only in motility disorders----Which could be deduced by the presntation of dysphagia to both liquids and solids simultaneously---
In case of obstructive lesion --->It is UGI scopy
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| arlete
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Where is said in the question "many years of symptoms"? Chronic GERD was concluded from what?
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