What is the most appropriate diagnostic imaging modality for a patient with chronic dysphagia (difficulty swallowing) for both solids and liquids, and a history of radiation exposure, given that a barium swallow is not an option?

From the Guidelines

For a patient with chronic dysphagia for both solids and liquids and a history of radiation exposure, where a barium swallow is not an option, the most appropriate diagnostic imaging modality is a fluoroscopy biphasic esophagram. This recommendation is based on the American College of Radiology (ACR) Appropriateness Criteria for dysphagia, which suggests that a biphasic esophagram is usually appropriate for the initial imaging of unexplained oropharyngeal dysphagia 1. The biphasic esophagram permits detection of both structural and functional abnormalities of the esophagus, including esophagitis, strictures, rings, and carcinoma, as well as functional abnormalities such as gastroesophageal reflux and motility disorders 1.

Given the patient's history of radiation exposure, it is crucial to choose an imaging modality that can accurately detect potential radiation-induced complications, such as strictures or esophagitis. The biphasic esophagram has been shown to have a high sensitivity for detecting esophageal cancer and other structural abnormalities, making it an ideal choice for this patient population 1.

Some key points to consider when choosing a diagnostic imaging modality for this patient include:

• The ability to detect both structural and functional abnormalities of the esophagus
• The sensitivity of the modality for detecting esophageal cancer and other potential complications of radiation exposure
• The availability and safety of the modality, given the patient's history of radiation exposure

In this case, a fluoroscopy biphasic esophagram is the most appropriate choice, as it meets all of these criteria and is recommended by the ACR Appropriateness Criteria for dysphagia 1.

From the Research

Diagnostic Imaging Modalities for Chronic Dysphagia

Given the patient's history of radiation exposure and the fact that a barium swallow is not an option, alternative diagnostic imaging modalities must be considered. The following options are available:

• Endoscopy: This is a viable alternative for diagnosing esophageal dysphagia, as it allows for direct visualization of the esophagus and can help identify any structural abnormalities or lesions 2, 3.
• High-resolution manometry: This test can help diagnose motility disorders of the esophagus, which can cause dysphagia to both solids and liquids 2, 3.
• Impedance planimetry: This test can provide information on esophageal distensibility and can be used to evaluate patients with non-obstructive esophageal dysphagia 2.
• Videoendoscopic evaluation of dysphagia (VEED): This is a non-radiographic method that can provide information on swallowing function and can be used as an adjunct to other diagnostic tests 4.

Considerations for Patients with Radiation Exposure

For patients with a history of radiation exposure, it is essential to minimize further radiation exposure whenever possible. Therefore, diagnostic imaging modalities that do not involve radiation, such as endoscopy and manometry, may be preferred 4.

Diagnostic Approach

A comprehensive diagnostic approach for chronic dysphagia should include a combination of clinical evaluation, patient history, and diagnostic tests. The choice of diagnostic test will depend on the patient's symptoms, medical history, and the suspected underlying cause of dysphagia 5, 2, 3.