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

Most Appropriate Initial Diagnostic Test for Substernal Chest Pain with Dysphagia

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

Rationale for Biphasic Esophagram

A biphasic esophagram is the preferred initial diagnostic test for several key reasons:

• It provides comprehensive evaluation of both structural and functional abnormalities of the esophagus 2
• It has high sensitivity (80-89%) and specificity (79-91%) for diagnosing esophageal motility disorders 1
• It offers excellent detection of peptic strictures with approximately 95% sensitivity 1
• It can identify multiple potential causes of substernal chest pain and dysphagia in a single examination, including:
  • Esophagitis
  • Strictures
  • Rings
  • Carcinoma
  • Motility disorders
  • Gastroesophageal reflux 2

Advantages Over Alternative Tests

1. Superior to single-contrast studies:

   • Provides better mucosal detail and visualization of structural abnormalities 2
   • Double-contrast technique offers superior depiction of mucosal processes 2

2. More appropriate than CT scan initially:

   • CT is usually not indicated as initial imaging because it does not adequately assess esophageal mucosa and motility 2
   • CT may be helpful in subsequent evaluation if initial studies are not revealing 2

3. More appropriate than endoscopy as first test:

   • While endoscopy is highly accurate for esophageal cancer and more sensitive for mild reflux esophagitis, it is invasive and typically performed after initial imaging 1
   • Studies suggest endoscopy is not routinely warranted to rule out missed tumors in patients with normal findings on barium studies 2

4. More appropriate than manometry:

   • Esophageal manometry is more suitable as a second-line test after structural abnormalities have been excluded 1
   • It helps characterize motility disorders initially detected on barium studies 1

Clinical Considerations

• In this patient with sudden onset of burning substernal chest pain and dysphagia for 3 hours, the biphasic esophagram can identify common causes such as:

  • Esophageal motility disorders (e.g., achalasia, diffuse esophageal spasm)
  • Structural abnormalities (e.g., strictures, rings)
  • Inflammatory conditions (e.g., esophagitis)
  • Less common but serious conditions like dissecting intramural hematoma of the esophagus 3

• While cardiac causes should be considered in patients with chest pain, the combination with dysphagia strongly suggests an esophageal etiology, making the biphasic esophagram the most appropriate initial test 1

Pitfalls to Avoid

• Do not start with CT scanning despite its increasing availability in emergency departments 4. While CT can evaluate for life-threatening causes of chest pain like aortic dissection and pulmonary embolism, it is not the optimal initial test when dysphagia is present with substernal chest pain 2

• Do not begin with single-contrast studies in cooperative patients, as they provide inferior mucosal detail compared to biphasic examination 2

• Remember that patient cooperation is required for optimal double-contrast technique. For elderly, debilitated, or obese patients who may not be able to fully cooperate, a single-contrast technique may be more suitable 2