A confusing Question from UW

[hsyn]

.A 45-year-old male presents with the complaint of difficulty swallowing both liquids and solids, which was mild initially but has worsened gradually. He also complains of nocturnal cough, which disturbs his sleep as well as regurgitation of undigested food eaten several hours earlier. Physical examination is unrevealing. Barium studies are performed which shows dilated esophagus, loss of esophageal peristalsis, and smooth tapering of the distal esophagus. What will be the most appropriate next step in the management of this patient?

a- ... .Esophagoscopy .
b- Barium
c-manometer



.The answer(UW) is . .Esophagoscopy is first ; manometer is second for diagnosis ..
..However MTB says: Barium is first test , most accurate test is manometer
What do you think?
Thanks.

.... .

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[Golding]

.A 45-year-old male presents with the complaint of difficulty swallowing both liquids and solids, which was mild initially but has worsened gradually. He also complains of nocturnal cough, which disturbs his sleep as well as regurgitation of undigested food eaten several hours earlier. Physical examination is unrevealing. Barium studies are performed which shows dilated esophagus, loss of esophageal peristalsis, and smooth tapering of the distal esophagus. What will be the most appropriate next step in the management of this patient?

a- . .Esophagoscopy .
b- Barium
c-manometer



.The answer(UW) is . .Esophagoscopy is first ; manometer is second for diagnosis ..
..However MTB says: Barium is first test , most accurate test is manometer
What do you think?
Thanks.

.

I don't recall the question 100%, but didn't that case mention a big history of smoking and drinking? I think the idea is you suspect carcinoma of the esophagus causing the achalasia.

 

[Doctor4Life1769]

I agree, if its purely dysphagia then barium as the initial test, confirm with manometry; if there is something in the hx suspecting a neoplasm/tumor then you want to visualize and attain bx so in this case it would be esophagoscopy.

 

[hsyn]

I don't recall the question 100%, but didn't that case mention a big history of smoking and drinking? I think the idea is you suspect carcinoma of the esophagus causing the achalasia.

No, It does not mention about history of smoking or drinking. However , in the explanation, it states that endoscopy should be first to rule out carcinoma!
45 years old, non smoker( I does not say smoker, so) , both solid and liquid dyspepsia --> achalasia ???
I do not know what I am missing?

 

[hsyn]

I agree, if its purely dysphagia then barium as the initial test, confirm with manometry; if there is something in the hx suspecting a neoplasm/tumor then you want to visualize and attain bx so in this case it would be esophagoscopy.

I think, the question is unclear. However I got the point. The test order is clear to me now.
Thank you guys.

 

[Doctor4Life1769]

No, It does not mention about history of smoking or drinking. However , in the explanation, it states that endoscopy should be first to rule out carcinoma!
45 years old, non smoker( I does not say smoker, so) , both solid and liquid dyspepsia --> achalasia ???
I do not know what I am missing?

Interesting. I've not started on the IM portion of UW yet. Figured it'd be tougher than Gen Surg, Psych, OBGYN (the toughest for me thus far but still managed a 68% overall) have been.

 

[Depakote]

No, It does not mention about history of smoking or drinking. However , in the explanation, it states that endoscopy should be first to rule out carcinoma!
45 years old, non smoker( I does not say smoker, so) , both solid and liquid dyspepsia --> achalasia ???
I do not know what I am missing?

While the patient most likely has achalasia the diagnostic algorithm calls for you to r/o pseudoachalasia (carcinoma presenting similarly to achalasia).

You can't call it something benign until you've made sure it isn't malignant.

 

[ygmd1980]

manometry is the gold standard... it does sound like you endoscopy to rule out Pseudo-achalasia(malignancy), was the question aiming at "next step" or "best step" ?

 

[OveractiveBrain]

Guys, the question is dead clear.

It says "I have worsening dysphagia" and "I have a h/o GERD"(in the question presenting with atypical symptoms).

Alarm Symptoms .was mild initially but has worsened gradually.
h/o GERD with obstructive symptoms .nocturnal cough, which disturbs his sleep as well as regurgitation of undigested food eaten

.Then the question goes on to yell you that "Ive already done the barium" (the thing most people miss because they go straight for endoscopy and biopsy). It is screaming I HAVE CANCER requiring a biopsy.

This guy probably has stricture 2/2 GERD but you have to rule out adenocarcinoma 2/2 GERD before you say "yep, benign process"

This guy does not have achalasia because it is rarely progressive, and does not present in the setting of GERD

 

[hsyn]

While the patient most likely has achalasia the diagnostic algorithm calls for you to r/o pseudoachalasia (carcinoma presenting similarly to achalasia).

You can't call it something benign until you've made sure it isn't malignant.

So , do you think we need to perform endoscopy to rule out carcinoma for all patient with dysphagia?

 

[hsyn]

Guys, the question is dead clear.

It says "I have worsening dysphagia" and "I have a h/o GERD"(in the question presenting with atypical symptoms).

Alarm Symptoms .was mild initially but has worsened gradually.
h/o GERD with obstructive symptoms .nocturnal cough, which disturbs his sleep as well as regurgitation of undigested food eaten

.Then the question goes on to yell you that "Ive already done the barium" (the thing most people miss because they go straight for endoscopy and biopsy). It is screaming I HAVE CANCER requiring a biopsy.

This guy probably has stricture 2/2 GERD but you have to rule out adenocarcinoma 2/2 GERD before you say "yep, benign process"

This guy does not have achalasia because it is rarely progressive, and does not present in the setting of GERD

I do not agree. It does not say GERD in the history. It is obstructive symptom of achalasia. It looks like achalasia :
-45 year is young for carcinoma
-.loss of esophageal peristalsis, and smooth tapering of the distal esophagus-->achalasia
-no history of smoking or drinking
-no history of melena


.

 

[rahulb]

EGD is ALWAYS the initial test or most appropriate NEXT step for ANY serious esophageal pathology when there is not a clear contraindication (esophageal perforation)

 

[Golding]

OveractiveBrain's post helps me remember it a bit better. The guy had GERD and it's a risk for Adenocarcinoma acting like Achalasia. It's one of two questions like that on USMLEWorld.

Can you post the question's ID#?

 

[thechad]

. regurgitation of undigested food eaten several hours earlier. ..
.

This does not necessarily mean GERD. It could be achalasia, zenker's diverticulum, gastroparesis, etc.

 

[Doctor4Life1769]

I must've not been paying attention (was in a hurry)

So, he had the barium study and it suggested achalasia. Since it is a progressive condition, I'd probably say that you do infact need to rule out possible Barret's first before you can move on to a more benign diagnosis of achalasia. You don't want to assume achalasia, and then later find out you missed a case of esophageal cancer that could have been treated medically at the time it was missed.

Nocturnal cough is almost always going to be discussed in reference to GERD. Especially with symptoms of dysphagia. You definitely want to rule out possible adenocarcinoma. Overactive brain is right in that regards.

 

[hsyn]

I must've not been paying attention (was in a hurry)

So, he had the barium study and it suggested achalasia. Since it is a progressive condition, I'd probably say that you do infact need to rule out possible Barret's first before you can move on to a more benign diagnosis of achalasia. You don't want to assume achalasia, and then later find out you missed a case of esophageal cancer that could have been treated medically at the time it was missed.

Nocturnal cough is almost always going to be discussed in reference to GERD. Especially with symptoms of dysphagia. You definitely want to rule out possible adenocarcinoma. Overactive brain is right in that regards.

OK. Here is detail explanation.
-Progressive motility dysphagia disorders include scleroderma or achalasia with chronic heartburn, regurgitation, respiratory problems, or weight loss.
- look at the algorithm:
http://en.wikipedia.org/wiki/Esophageal_dysphagia
- carcinoma: Age. Most patients are over 60, and the median in US patients is 67.

So it is most likely achalasia.He has no risk for carcinoma( except gender).
As for GERD, this symptoms are related to obstruction . if it stated , he has GERD for 20 years you might be right.
Thank you for good discussion.

 

[kevster2001]

Any patient over 40 who presents with swallowing difficulty, ALWAYS SCOPE. Delaying the diagnosis of achalasia wont make a difference except for quality of life. Delaying the diagnosis of carcinoma can mean the diff between life and death.

Yes he's slightly young for cancer, but if you wait until the average age of onset to be suspicious, you've already missed half the cases.


The question is asking about "what is the most appropriate next step," not "what is the most likely diagnosis."

 

[kdburton]

OK. Here is detail explanation.
-Progressive motility dysphagia disorders include scleroderma or achalasia with chronic heartburn, regurgitation, respiratory problems, or weight loss.
- look at the algorithm:
http://en.wikipedia.org/wiki/Esophageal_dysphagia
- carcinoma: Age. Most patients are over 60, and the median in US patients is 67.

So it is most likely achalasia.He has no risk for carcinoma( except gender).
As for GERD, this symptoms are related to obstruction . if it stated , he has GERD for 20 years you might be right.
Thank you for good discussion.

The other clue to get you thinking of GERD is the nocturnal cough that disturbs his sleep. The patients in these questions don't have to have every classic symptom and a lack of every other distracting symptom - they just need enough to put a serious disease on your differential that you should rule out in the beginning of your workup.

 

[Golding]

Kaplan's QBank has had a couple questions like this too. Seems that being over 35 years old is reason enough to be concerned enough about esophageal cancer to want to rule it out.

 

[yalemd]

-C/P and Barium suggest Achalasia.
-No risk factors for SCC (smoking or alcohol) but there is a risk factor for AdenoCa; chronic reflux->Barret's->AdenoCa
-Next Step: Scope it and get a Bx to r/o Barret's
-Manomentry is the most accurate (gold standered), to confirm Dx, but not next best step.
-Barium already done.