What is the most appropriate initial diagnostic test for a patient presenting with sudden onset of burning substernal chest pain and dysphagia?

Initial Diagnostic Test for Sudden Onset Burning Substernal Chest Pain with Dysphagia

A fluoroscopy biphasic esophagram is the most appropriate initial diagnostic test for a 45-year-old man presenting with sudden onset of burning substernal chest pain and dysphagia. 1

Rationale for Biphasic Esophagram

The American College of Radiology (ACR) Appropriateness Criteria specifically recommends a biphasic esophagram as the initial imaging test for patients with retrosternal dysphagia, which directly applies to this case:

• The patient presents with classic symptoms of retrosternal dysphagia (difficulty swallowing) combined with substernal chest pain
• The biphasic esophagram provides superior evaluation of both esophageal structure and function
• This test has high diagnostic yield for the most likely causes of these symptoms

Diagnostic Capabilities of Biphasic Esophagram

• High sensitivity (80-89%) and specificity (79-91%) for diagnosing esophageal motility disorders 1
• Excellent detection of peptic strictures with sensitivity of approximately 95% 1
• Superior mucosal detail compared to single-contrast studies, allowing visualization of:
  • Esophageal inflammation
  • Ulceration
  • Strictures
  • Motility disorders (achalasia, diffuse esophageal spasm)
  • Masses

Why Other Tests Are Less Appropriate Initially

Chest Radiography

• Limited utility as initial test for dysphagia with chest pain
• Cannot adequately assess esophageal mucosa or motility 1
• May be helpful as a subsequent test if initial studies are non-diagnostic

CT Scan of Chest

• "Usually not indicated as an initial imaging modality in this clinical scenario because it does not assess esophageal mucosa and motility" 1
• More appropriate for subsequent evaluation if initial studies are non-revealing

Esophageal Manometry

• Second-line test after imaging studies
• More appropriate after structural abnormalities have been excluded
• Often performed to further characterize motility disorders initially detected on barium studies 1

Upper GI Endoscopy

• Invasive procedure typically performed after initial imaging
• More appropriate when biopsy or direct visualization is needed
• Not recommended as the first diagnostic test in this clinical scenario

Clinical Considerations

The patient's presentation with burning substernal chest pain and dysphagia for 3 hours suggests several possible diagnoses:

• Esophageal motility disorders (e.g., diffuse esophageal spasm, achalasia)
• Gastroesophageal reflux disease with esophagitis
• Esophageal stricture
• Esophageal inflammation or infection

The biphasic esophagram can effectively evaluate for all these conditions as the initial diagnostic test, guiding subsequent management decisions.

Important Caveat

While evaluating for esophageal pathology, it's essential to consider that substernal chest pain may also represent cardiac pathology. Appropriate cardiac evaluation should be performed concurrently with the gastrointestinal workup, especially in a 45-year-old man presenting at 3 AM with chest pain.