Achalasia With Red Flags Wt loss and awakening from sleep

[medInUSA]

I did a Kaplan Q bank question where it presented a patient with dysphagia for both solids a liquids. A Barium swallow was done and revealed a bird's peak appearance (great, I thought at that point, pathognomonic for Achalasia!!!).
Then it also mentions that the patient had recent rapid weight loss and the epigastric pain that awakens him from sleep.

the question asked the next diagnostic step.

I chose esophageal monometry to confirm the diagnosis of achalasia.
🙁

however the answer was endoscopy!!! Since this is a patient who has achalasia but ALSO has red flags of weight loss and being awoken from sleep, we have to suspect achalasia secondary to gastroesophogeal cancer. And thus we must do an endoscopy looking for that cancer!!!!

Now I just did a UWorld Question.
3 month history of dysphagia for liquids and solids. 10 pound weight loss over 2 months. Lateral X ray shows extreme dilation of the esophagus with an air fluid level. Which is the next diagnostic test???


great I thought, similar question, achalasia with the red flag of rapid weight loss, so we must suspect achalasia secondary to gastroesophogeal cancer. So I choose endoscopy!!
NO the answer this time is monometry. It says in the explanation "the diagnosis of achalasia is made with monometry, however the endoscopy is required to make sure there is no malignancy". So it's required but you wouldn't do it next, you would do the monometry?? What the hell is going on. Whats the next best diagnostic test in this situation???????

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[tfom08]

I didn't do the Kaplan question, but I remember that UW question and I missed it as well. I think the inclusion of wt loss (red flag symptom) was a poor decision and made the question very debateable. I've noticed that some questions on UW ask for best DIAGNOSTIC test or like in this case "next DIAGNOSTIC test" and what they seem to be looking for is the test with the highest specificity for the condition the pt has, even if it isn't normally the next step in the workup. I guess if it would have said "next step in the workup" it would have been more likely to be endoscopy. Having said that, I agree that it's a poorly written question and I think on the real exam it wouldn't be so vague. Either only one of the choices would be on there or the red flag symptom would be missing. Having said that, I believe I have read that you always need to do endoscopy when diagnosing achalasia because gastric carcinoma can cause it even in the absence of red flag symptoms. Any comment on that?

 

[medInUSA]

I didn't do the Kaplan question, but I remember that UW question and I missed it as well. I think the inclusion of wt loss (red flag symptom) was a poor decision and made the question very debateable. I've noticed that some questions on UW ask for best DIAGNOSTIC test or like in this case "next DIAGNOSTIC test" and what they seem to be looking for is the test with the highest specificity for the condition the pt has, even if it isn't normally the next step in the workup. I guess if it would have said "next step in the workup" it would have been more likely to be endoscopy. Having said that, I agree that it's a poorly written question and I think on the real exam it wouldn't be so vague. Either only one of the choices would be on there or the red flag symptom would be missing. Having said that, I believe I have read that you always need to do endoscopy when diagnosing achalasia because gastric carcinoma can cause it even in the absence of red flag symptoms. Any comment on that?

According to Conrad Fischer, USMLE Master the boards step 3 page 167
"Endoscopy is NOT necessary to diagnose achalasia. Monometry would show absence of esophogeal peristalsis and normal or high pressure at the LES, since achalasia involves failure of the gastroesophogeal sphincter to relax. There is no mucosal abnormality"

 

[medInUSA]

Oh my God!!!

just came upon another Uworld quesion:

68 year old man presents with a 2 month history of dysphagia for both solids and liquids. He has had a 6.6 lb weight loss over this time. His PMH is remarkable for TIA 6 mos ago, two bouts of pneumonia in the past 3 months, and chronic heartburn treated with over the counter antacids. Physical shows a supple neck without masses. Abdominal exam shows mild epigastric tenderness to deep palpation. Chest X ray is normal for his age. Which of the following is the most appropriate next step in the diagnosis?

a Endoscopy
b barium

I am thinking again a motility problem probably achalasia (but since GERD sxs are present scleroderma is also possible but unlikely given his age and lack of other sxs of scleroderma) and then there's the WEIGHT LOSS. now how to judge if its significant, since they don't give me the weight of this patient.
Anyway I am thinking achalasia with the red flag of weight loss and go for endoscopy.
NO😡 😱
the answer is barium.

and what's more perplexing is their explanation:

" dysphagia for both solids and liquids suggests an underlying motility disorder (OK great I am with you!!!) . Standard assessment of the esophagus usually begins with a barium swallow (Excuse me?? what if there are red flags of weight loss or waking up at night, aren't you supposed to go straight to the endoscopy?)
Educational Objective: Barium swallow is the initial test of choice for all patients with dysphagia (WHAT???? what if the dysphagia is for solids more than liquids, which makes you suspect esophageal cancer and then the best initial test is endoscopy??? Or what if there are red flags of rapid weight loss or waking up at night shouldn't you go straight to endoscopy??? How can they make this sweeping statement that barium is the initial test of choice for ALL patients with dysphagia???). Subsequent endoscopy is dependent on the barium swallow findings."

Corad Fischer says on page 168 of "USMLE master the boards step 3":
"esophageal cancer:
Diagnostic testing is as follows:
-the best initial test is ENDOSCOPY
-if endoscopy is not one of the answer choices then barium swallow can be performed."

I am completely losing my marbles, or are these Uworld ppl smoking something they shouldn't be smoking when writing questions and explnations???

 

[medInUSA]

And this video also goes against what Uworld says about Barium ALWAYS being the best initial test for dysphagia:

http://www.youtube.com/watch?v=2_Df18s-FjE&feature=related

 

[synapse lapse]

Man I missed like 3 of those freaking questions on UW, I never seem to get what the next diagnostic step is lol.

 

[tfom08]

Haha, I remember thinking all of these same things as I went through these questions. I think I would put barium swallow for the first test if I'm looking for achalasia after reading all of the UW questions. I don't base that on any quality resources, but it seems like in most cases of achalasia where they want the next step, they already give you the barium swallow (as in OPs first post) so I'm guessing if they haven't done any workup at all, you start with barium swallow. Really, it's just a who knows type thing.

 

[radslooking]

i think that a greater than 10 lb weight loss or severe reflux (>6 mo and certainly greater than 2 years) warrants an endoscopy. Anything that could suggest cancer.

That being said, anything less than that and I would do barium and confirm with manometry. (with an endoscopy probably needed later anyway)

 

[DrWBD]

The question of EGD vs. barium swallow for dysphagia is actually a somewhat controversial area.

I agree with barium swallow as the first test. It's generally not a good idea to start with endoscopy if an obstructive process is suspected. A supine patient who is sedated for endoscopy is at an increased risk of aspiration. The barium swallow gives the so-called "roadmap" that will let the endoscopist know what to expect, including consideration for airway protection with intubation prior to the procedure.

Manometry is definitely the wrong answer though. The bird-beak appearance can also be caused by an intrinsic or extrinsic malignant process ("pseudoachalasia") and EGD is warranted to rule out esophageal obstruction. If that is negative, it is still a good idea to do a CT scan first to rule out extrinsic compression, then do the manometry to confirm the diagnosis of achalasia.

A manometry study is NEVER performed before a thorough visual evaluation of the esophagus (EGD).

 

[tfom08]

The question of EGD vs. barium swallow for dysphagia is actually a somewhat controversial area.

I agree with barium swallow as the first test. It's generally not a good idea to start with endoscopy if an obstructive process is suspected. A supine patient who is sedated for endoscopy is at an increased risk of aspiration. The barium swallow gives the so-called "roadmap" that will let the endoscopist know what to expect, including consideration for airway protection with intubation prior to the procedure.

Manometry is definitely the wrong answer though. The bird-beak appearance can also be caused by an intrinsic or extrinsic malignant process ("pseudoachalasia") and EGD is warranted to rule out esophageal obstruction. If that is negative, it is still a good idea to do a CT scan first to rule out extrinsic compression, then do the manometry to confirm the diagnosis of achalasia.

A manometry study is NEVER performed before a thorough visual evaluation of the esophagus (EGD).

Thanks for that explanation. Very clear, it's nice when people with real life experience can give some guidance.

I will say I took Step 2 yesterday and without giving away test details, lets just say that in a very similar situation, USMLE sidesteps the controversy by not including both viable treatment options when there is debate about which of two treatment options is best. I think the deal with USMLEWorld is that a lot of times they make you choose between two very equal options and sometimes two questions in the bank even directly contradict each other (I can recall at least 3-4 instances), but on Step 2 CK, they will not include such equal options. Use UW as a good learning tool, but count on not having to choose between treatments unless the benefit of one or the other is clear.

 

[superocker]

well let me summarise what kaplan says about this deal

best inital test overall -barium swallow

best confirmatory test for achalasia- esophageal manometry

achalasia with alarm symptoms-endoscopy

I guess what is confusing once I reread the question thrice is the weight loss
well if you cant eat solid food you are bound to lose weight .............

I guess they are saying 10 pounds in 2 months is acceptable for someone not being able to eat solid foods.....but then they should have included this in the explanation on what they think off rapid weight loss....

The third question is easy I am sure 6.6 lb in 2 months is acceptable if you cant eat solid food !
so yes the answer to the third question was acceptable

I agree on the ambiguity of the first 2 questions



confirmatory test - esophageal manometry

best treatment-pneumatic dilation

mc complication of treatment -perforation (5% chances)

I am doing UW randomly (like in a random mode)....so I dont get questions from similar divisions !

 

[Gastrapathy]

As was previously stated, mano before endoscopy should never happen. Even if you could exclude pseudoachalasia without endoscopy (you can't), you want the endoscopy to assist with interpretation of the manometry (hiatal hernias can be confusing).

Whether to start with endoscopy or barium depends on a variety of factors, mostly related to access and who the patient is seeing. Aspiration is quite uncommon and most endoscopists don't think we need a roadmap. If I think a patient has an obstruction, the last thing I want is a column of barium between me and the lesion. The advantage of barium is that it can give you some functional info as well as anatomic info. For a patient with red flags, I usually start with an endoscopy because I don't want to delay dx of CA. For patients where I suspect achalasia, its dealers choice.

As for tx of achalasia, most experts (though not the preeminent gastroenterologist in the field, Don Castell) recommend Heller myotomy over pneumatic dil. That being said, the practice is changing back towards more dils.

 

[medInUSA]

Thank you to all the Gastroenterologists who responded on this board. We really appreciate it.

(I had posted a link in the GI message board with a link to this thread asking for their help).

 

[Firebird]

now how to judge if its significant, since they don't give me the weight of this patient.

for it to be significant, he would have to weigh 66 lbs.

 

[MElSorady]

According to Conrad Fischer, USMLE Master the boards step 3 page 167
"Endoscopy is NOT necessary to diagnose achalasia. Monometry would show absence of esophogeal peristalsis and normal or high pressure at the LES, since achalasia involves failure of the gastroesophogeal sphincter to relax. There is no mucosal abnormality"

I agree with you. Endoscopy is not necessary in that case. But being associated with Wt Loss (red flag) of high risk of Ca/ we should do endoscopy 1st to roll it out, then manometry to confirm the Dx of achalasia. That;s what I think, Please advice.

 

[Vision]

I did a Kaplan Q bank question where it presented a patient with dysphagia for both solids a liquids. A Barium swallow was done and revealed a bird's peak appearance (great, I thought at that point, pathognomonic for Achalasia!!!).
Then it also mentions that the patient had recent rapid weight loss and the epigastric pain that awakens him from sleep.

the question asked the next diagnostic step.

I chose esophageal monometry to confirm the diagnosis of achalasia.
🙁

however the answer was endoscopy!!! Since this is a patient who has achalasia but ALSO has red flags of weight loss and being awoken from sleep, we have to suspect achalasia secondary to gastroesophogeal cancer. And thus we must do an endoscopy looking for that cancer!!!!

Now I just did a UWorld Question.
3 month history of dysphagia for liquids and solids. 10 pound weight loss over 2 months. Lateral X ray shows extreme dilation of the esophagus with an air fluid level. Which is the next diagnostic test???


great I thought, similar question, achalasia with the red flag of rapid weight loss, so we must suspect achalasia secondary to gastroesophogeal cancer. So I choose endoscopy!!
NO the answer this time is monometry. It says in the explanation "the diagnosis of achalasia is made with monometry, however the endoscopy is required to make sure there is no malignancy". So it's required but you wouldn't do it next, you would do the monometry?? What the hell is going on. Whats the next best diagnostic test in this situation???????

Having a "bird beak" appearing on barium is NOT pathognomonic for achalasis as entity such as a pseudo-achalasia can have this appearance. When I say pseudo-achalasia I mean extrinsic compression (like a cancer), certain type of stricture etc.... So, question #1, with patient presenting with weight loss i.e. red flags, the first thing to do is to r/o the most worrisome diagnosis, in this case, cancer. Also, patient typically DO NOT present with RAPID weight loss and ABDOMINAL PAIN which were both symptoms from question 1

I think the key clue that the second question give you is the DILATED ESOPHAGUS! which is a sign of chronicity. What happens is the peristalasis of the esophagus is completely gone (due to the strong lower esophageal sphincter pressure or in this case achalasia), therefore, you need to perform monometry.

In real life, you would do endoscopy as first diagnostic exam when patient present with dysphagia.... so don't feel bad

 

[newspeak]

So guys, what is the bottom line here in the steps?! basically our two attendings have different approaches here.