Discrepancy help: Pestana vs. UWorld

[kaleerkalut]

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Some help appreciated. Pestana states that for what "sounds like achalasia" should get barium swallow first and then manometry studies. UWorld states barium swallow first and then upper endoscopy. If both of these are negative or indeterminate, then go to manometry studies. Which one is correct? Thanks in advance 🙂

 

[Winged Scapula]

Manometry is mandatory as the diagnosis of achlasia requires failure of the LES to relax, so UWorld is not really telling the whole story.

In the real world, all 3 tests are done, without real regard to order.

The following makes sense to me:

Patient with symptoms of dysphagia ----> UGI followed by EGD then manometry (but if I could get the manometry done first, I'd change the order). That's the problem with these tests. Too artificial.

-UGI will delineate dilation/tortuosity of esophagus and help you make sure it isn't Zenkers (for which you do not generally want to do EGD)
-EGD will allow for assessment of mucosa (is there a esophagitis, a mucosal ulcer,mass or submucosal mass) and to remove any retained food; it is not going to give you pressures required for diagnosis
-Manometry allows for assessment of peristalsis and LES pressures (which are again, diagnostic and will assist in surgical planning)

Finally, some add a 24 hr pH probe although generally not necessary.

So which one is right? I'd say neither - manometry is required to make the diagnosis of achlasia but you also want an EGD if you're planning on operating to make sure there isn't a mass causing dysphasia and pseudoachalasia. Only in that case would manometry not be necessary.

The question makes it sound like if the EGD and upper G.I. were normal, then that would be the only reason to have manometry. My sense is that unless one of those examination shows that the diagnosis is not achalasia then manometry is warranted.

That probably wasn't much help was it? 😳

 

[Kaputt]

I remember thinking about this too when doing questions for surgery. UWorld made the argument that you could get "pseudoachalasia" from an esophageal tumor. So if the patient has an achalasia-looking barium swallow but also has those constitutional cancer signs/symptoms, you have to rule out a really low obstructive tumor before ordering a test to confirm achalasia.

Tricky question that I got wrong.

 

[Winged Scapula]

I remember thinking about this too when doing questions for surgery. UWorld made the argument that you could get "pseudoachalasia" from an esophageal tumor. So if the patient has an achalasia-looking barium swallow but also has those constitutional cancer signs/symptoms, you have to rule out a really low obstructive tumor before ordering a test to confirm achalasia.

Tricky question that I got wrong.

UWorld is correct in that sense: you do need an EGD to rule out a mass causing pseudoachalasia and if it were positive, then you wouldn't necessarily need manometry. The trick is in the presentation: by mentioning achalasia your mind is heading down that path And they imply that manometry is only necessary if those other two exams are normal. Those two will likely be abnormal as well with achalasia.