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

Biphasic Esophagram is the 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 biphasic esophagram. 1

Rationale for Biphasic Esophagram as First-Line Test

The American College of Radiology specifically recommends a biphasic esophagram as the preferred initial diagnostic test for patients presenting with symptoms like this patient's, offering:

• High sensitivity (80-89%) and specificity (79-91%) for diagnosing esophageal motility disorders 1
• Excellent detection of various conditions including esophagitis, strictures, rings, carcinoma, and gastroesophageal reflux 1
• Superior mucosal detail compared to single-contrast studies, allowing visualization of esophageal inflammation, ulceration, and motility disorders 2, 1

Comparison with Alternative Diagnostic Options

1. Barium swallow (single contrast): Less preferred than biphasic esophagram due to inferior mucosal detail, though may be appropriate if the patient is too debilitated to tolerate a double-contrast examination 2

2. Chest radiography: Not indicated as an initial imaging modality as it provides limited information about esophageal mucosa and motility disorders 2

3. CT scan of chest: Not recommended as the initial test because it does not adequately assess esophageal mucosa and motility. May be helpful in subsequent evaluation if initial studies are not revealing 2, 1

4. Esophageal manometry: More appropriate as a second-line test after imaging studies to further characterize motility disorders initially detected on barium studies 1

5. Upper gastrointestinal endoscopy: While valuable for obtaining specimens (histology, cytology, immunostaining, or culture), endoscopy is typically reserved for after initial imaging or when biopsy is needed 2, 1

Clinical Considerations

• The patient's presentation with burning substernal chest pain and dysphagia for 3 hours suggests possible esophageal pathology such as:

  • Esophagitis
  • Motility disorders
  • Possible intramural hematoma 3

• A biphasic esophagram can quickly identify structural and functional abnormalities that might explain these symptoms while being less invasive than endoscopy 1

Important Caveats

• While focusing on the esophageal cause of symptoms, appropriate cardiac evaluation should be performed concurrently, especially given the presentation of substernal chest pain 1

• Patient cooperation is required for optimal double-contrast technique; if the patient cannot fully cooperate, a single-contrast esophagram may be more suitable 2, 1

• If the biphasic esophagram reveals abnormalities, subsequent endoscopy may be warranted for tissue sampling and definitive diagnosis 2