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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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Age more than 60 and solid food dysphagia...esophageal ca more than achalasia(both solid n liquid) DD esophagoscopy
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red flags ---age> 40 and progressive dysphagia so DD
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i change to A
Schatzki ring clue =discomfort in the mid-lower chest after eating meats or dry bread.
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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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may be i am confused here.....but in mid/lower esophageal strictures uw recommends cotrast xrays 1st to see the anatomy to avoid peforations/injuries before putting endoscope in. any way
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@captan am confused about this answer, in the question there was nowhere they mentioned that the patient was having repeat GERD over the years, his physical exam was normal, no weight lost, so i thought from uworld when there is esophageal dysmotility the first step is contrast esophagraphy ----> esophagoscopy----> manometry.
so am kind of confused that the answer was esopahgoscopy and not barium esophagram
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@allsteps123...you have a point.
But my confusion is, pt has h/o dysphagia to solids stuff only, indcating a structural problem in the esophagus.......and if benign stricture is a consideration....then why not most appropriate next step should be contrast xray to see the unseen anatomy of esophagus to avoid damage for the reason i posted above.
-most appropriat initial step OR most approprite next step. ....do they not carry the same meaning or not.??
- my intenion is to get rid of my confusion only. REGARDS
