From the Guidelines
The next best step in diagnosing a patient with progressive dysphagia and chest pain is to perform high-resolution esophageal manometry, as the patient has already undergone upper endoscopy with a normal appearing esophagus and negative biopsies for eosinophilic esophagitis 1. This approach is supported by the British Society of Gastroenterology guidelines, which recommend manometry in patients with dysphagia after endoscopy and biopsies have been performed to rule out mucosal and structural disorders 1.
Diagnostic Considerations
The patient's symptoms of progressive dysphagia and chest pain raise concern for motility disorders, such as achalasia or distal esophageal spasm, which can be diagnosed with esophageal manometry 1. The American Heart Association guidelines also support the use of manometry in the evaluation of chest pain, particularly when gastrointestinal causes are suspected 1.
Alternative Diagnostic Tests
While a CT scan to rule out tumors or extrinsic compression (option A) and an empiric trial of twice daily proton pump inhibitor therapy (option C) may be considered, they are not the next best step in this patient's diagnosis. A functional luminal imaging probe (option D) is also not the preferred initial test.
Clinical Decision Making
In clinical practice, it is essential to prioritize diagnostic tests that provide the most information and have the potential to guide therapeutic decisions. In this case, high-resolution esophageal manometry is the most appropriate next step, as it can help diagnose motility disorders and guide further management 1. The patient's symptoms and normal endoscopy results support the use of manometry as the next best step in the diagnostic work-up.
From the Research
Diagnostic Approach
The patient presents with progressive dysphagia and chest pain, with a normal appearing esophagus on upper endoscopy and negative esophageal biopsies for eosinophilic esophagitis. The next best step in the diagnostic work-up would be to investigate the motility of the esophagus.
Rationale
- The patient's symptoms of dysphagia and chest pain are consistent with esophageal motility disorders, such as achalasia or diffuse esophageal spasm 2, 3.
- High-resolution esophageal manometry is a reliable tool for assessing esophageal motor function and diagnosing motility disorders 4, 5.
- Endoscopy has already been performed, and the esophagus appears normal, making other diagnostic tests like CT scan or empiric trial of proton pump inhibitor therapy less likely to yield a diagnosis at this stage.
Recommended Next Step
- High-resolution esophageal manometry (option B) is the most appropriate next step in the diagnostic work-up to evaluate the patient's esophageal motility and diagnose any underlying motility disorders 2, 4, 5.
Alternative Options
- A CT scan to rule out tumors or extrinsic compression (option A) may be considered if the manometry results are inconclusive or if there are other clinical indications for a CT scan.
- An empiric trial of twice daily proton pump inhibitor therapy (option C) may be considered if gastroesophageal reflux disease (GERD) is suspected, but this would not be the primary next step in this case.
- Functional luminal imaging probe (option D) may provide adjunctive information in some cases, but it is not the primary diagnostic tool for esophageal motility disorders 5.