Is a KUB (Kidney, Ureter, Bladder) X-ray necessary for a patient with an esophageal stricture who underwent EGD (Esophagogastroduodenoscopy) with dilation and now presents with a firm abdomen and severe discomfort after eating a large meal?

Management of Abdominal Discomfort After Esophageal Dilation

A KUB (Kidney, Ureter, Bladder) X-ray is not necessary for this patient with esophageal stricture who has abdominal discomfort after a large meal following recent EGD with dilation. The symptoms are most likely due to postprandial discomfort related to the recent procedure and excessive food intake.

Understanding the Current Presentation

The patient's symptoms can be explained by:

• Recent esophageal dilation procedure
• Excessive food intake ("a lot of food for dinner")
• Firm abdomen without other concerning features
• Sensation of stomach "going to explode"

Rationale for Not Performing KUB

1. Post-dilation symptoms are expected:

   • Chest pain and discomfort are common after esophageal dilation, especially in patients with esophageal strictures 1
   • Patients should be informed that chest/abdominal pain after dilation is common, particularly in those with eosinophilic esophagitis 1

2. Timing and nature of symptoms:

   • The patient's symptoms appeared after a large meal
   • The abdominal firmness is consistent with gastric distention from overeating
   • The timing suggests postprandial discomfort rather than a procedural complication

3. Absence of concerning features:

   • No fever, tachycardia, or breathlessness that would suggest perforation
   • Guidelines recommend imaging only when patients develop persistent chest pain, fever, breathlessness or tachycardia during recovery 1

Management Approach

1. Conservative measures:

   • Reassurance that symptoms are likely due to overeating after the procedure
   • Small, frequent meals rather than large meals in the post-dilation period
   • Continue prescribed acid suppression therapy (typically PPI)

2. Monitoring:

   • Observe for resolution of symptoms with conservative management
   • Provide contact information for the on-call team should symptoms worsen 1

3. When to consider imaging:

   • Development of persistent chest pain (beyond expected post-procedural discomfort)
   • New fever, tachycardia, or respiratory distress
   • Progressive abdominal distention or new peritoneal signs

Important Considerations After Esophageal Dilation

• Perforation risk after esophageal dilation is approximately 0.5-1.1% for benign strictures 1
• Suspect perforation when patients develop persistent pain, breathlessness, fever or tachycardia 1
• Transient chest/abdominal discomfort is common and expected
• Patients should be advised to consume smaller meals initially after dilation

Follow-up Recommendations

• Dietary counseling regarding appropriate food choices and portion sizes
• Continued acid suppression therapy if the stricture is peptic in nature
• Scheduled follow-up to assess symptom improvement
• Consideration of repeat dilation sessions if dysphagia recurs (weekly or two-weekly sessions until easy passage of a ≥15 mm dilator is achieved) 1

In summary, this patient's presentation is consistent with expected post-dilation discomfort exacerbated by excessive food intake, and a KUB X-ray is not indicated at this time unless symptoms worsen or new concerning features develop.