prep4step2
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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
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| asmi
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D...
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| daira
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I think workup for any suspected esophageal problem needs to be started with Ba. So my answer is A.
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| BellKicker
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I think D is right.
Does anyone use barium studies much, anymore, guest? For achalasia, maybe but other than that I think they are a little archaic.
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| prep4step2
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asmi & Bellkicker, you guys are great. You're right again.
Guest, I'm with you, 'cause I chose barium enema as well.
Shouldn't barium be the 1st workout for esophagus disease always? At least Kaplan notes say so. Plus, it's asking for "next step" instead of "best step" of evaluation.
asmi & Bellkicker, can you clarify this?
Again, many thanks!
****************************************************
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.
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| daira
Forum Senior
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Kaplan's Pearls regarding esophageal diseases say:
First test for all dysphagias is Ba.
May be there is something about 'next most appropriate step'. Next most appropriate means the best step or most specific in making diagnosis??
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| tess
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I have two doubts about this question:
1) in explanation, it goes to the diagnosis as complication of GERD, do u guys agree? To me, it is more like a case of Achalasia.
2) Achalasia is a motility disorder not mechanical disorder, so according to CMDT, barium esophagoscopy should be done first.
But honestly, this is a topic have been causing a lot of discussion.
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| lucky
Forum Guru
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i agree with guest.
kaplan says that esophageal motility disorders merit a barium enema first .
this is reallyconfusing. should we follow kaplan or some other source?
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| asmi
Forum Hero
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prep4step2,
I thought that he probably has osophageal stricture..and doing oesophagoscopy will be both diagnostic and therapeutic in this case.
clues in here were his age (looks long h/o GERD) and that he cannot even eat bread ...
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| Dot
Forum Senior
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the best is ogd scopy but next appropriate is barium .
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| daira
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I think the 'most appropriate next' step means the step which d lead to the diagnosis. Its probably the same as 'most useful' step.
Its different from 'immediate next step', which actually means what comes next in management.
Thats what I could get from kaplan videos.
Any thoughts ??
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| dimps
Forum Guru
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i too agree with guest as kaplan notes say
first test to do in all cases of dysphagia is barium swallow
i m very much confused ,can any body tell me which is the correct answer
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| daira
Forum Senior
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Now I think D is the right answer. Hx of GERD, peptic stricture, age above 50 --> EGD.
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| merrk
Forum Elite
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Tess, in achalasia there would be dysphagia to both solids and liquids.
Since we're not suspecting a motility disorder, I agree with D
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