From the Guidelines
The best investigation for a suspected paraoesophageal hernia in an old female with dysphagia relieved by a large loud belch is a barium swallow study, specifically a fluoroscopy biphasic esophagram. This radiographic examination provides excellent visualization of the esophagus and stomach, allowing for dynamic assessment of the hernia during swallowing, as noted in the study by 1. The test involves the patient drinking a contrast medium (barium) while fluoroscopic images are taken, which can demonstrate the herniated portion of the stomach above the diaphragm, the size of the hernia, and any associated complications.
Key Points to Consider
- A barium swallow study is preferred because it provides both anatomic and functional information on esophageal length, esophageal stricture, presence of gastroesophageal reflux, and reflux esophagitis, as highlighted in the study by 1.
- An upper endoscopy (esophagogastroduodenoscopy) would be a valuable complementary investigation to assess the esophageal and gastric mucosa for complications such as inflammation or ulceration, but it is not the first line of investigation for diagnosing paraoesophageal hernias, as suggested by 1.
- CT scanning may also be helpful in complex cases to evaluate the full extent of the hernia and surrounding structures, but it is not the primary investigation for this condition.
- The patient's symptom of dysphagia relieved by belching is classic for a paraoesophageal hernia, as the belch likely reduces the herniated stomach temporarily, relieving the obstruction, which aligns with the findings in 1.
Rationale for Choosing Barium Swallow
The choice of barium swallow as the best investigation is based on its ability to provide detailed images of the esophagus and stomach, allowing for the diagnosis of paraoesophageal hernias and associated complications, as noted in 1. Additionally, the study by 1 supports the use of fluoroscopy biphasic esophagram for detecting structural and functional abnormalities of the esophagus, including hiatal hernias. This investigation is particularly appropriate for elderly patients as it is non-invasive, well-tolerated, and provides the necessary anatomical information to guide management decisions.
From the Research
Diagnostic Investigations for Paraoesophageal Hernia
The best investigation for a suspected paraoesophageal hernia in an old female with dysphagia relieved by a large loud belch can be determined by considering the following options:
- Barium Swallow: This investigation is useful in evaluating the anatomy of the esophagus and stomach, and can help identify the presence of a hiatal hernia 2, 3.
- Upper Endoscopy: This procedure allows for direct visualization of the esophagus, stomach, and duodenum, and can help identify any abnormalities such as strictures, diverticula, or Barrett's esophagus 4, 2.
- CT Abdomen and Chest with Contrast: This imaging study can provide detailed information about the anatomy of the esophagus, stomach, and surrounding structures, and can help identify any complications such as incarceration or strangulation of the hernia.
Recommended Investigation
Based on the available evidence, Barium Swallows is considered a useful investigation in the diagnosis of paraoesophageal hernias, particularly in patients with dysphagia 3. However, Upper Endoscopy is also an important diagnostic tool, as it can help identify any underlying conditions that may be contributing to the patient's symptoms 4, 2. CT Abdomen and Chest with Contrast may also be useful in certain cases, particularly if there is suspicion of complications such as incarceration or strangulation of the hernia. Therefore, the best investigation for this patient would likely be B. Barium swallows, as it is a non-invasive and relatively low-risk procedure that can provide valuable information about the anatomy of the esophagus and stomach 4, 3.