Question 1: Best Diagnostic Test for Hypertensive LES with Dysphagia and Weight Loss
Endoscopy with biopsy is the best diagnostic test for this patient because weight loss and dysphagia are alarm features that mandate immediate endoscopic evaluation to exclude esophageal or gastric malignancy. 1
Rationale for Endoscopy as First-Line Test
The American College of Gastroenterology explicitly recommends endoscopy with biopsy as the best diagnostic test for patients presenting with central chest pain, dysphagia, weight loss, and hypertensive lower esophageal sphincter. 1
Weight loss combined with dysphagia has the best performance characteristics for identifying esophageal or gastric malignancies, making endoscopy the appropriate initial test rather than other modalities. 1
Endoscopy is highly accurate for esophageal cancer when multiple biopsy specimens and brushings are obtained. 1
Essential Biopsy Protocol
Obtain at least 5 esophageal mucosal biopsy specimens during endoscopy to evaluate for eosinophilic esophagitis, which can present with dysphagia and may be missed on visual inspection alone. 1
Multiple biopsies are critical because eosinophilic esophagitis can appear endoscopically normal yet cause significant symptoms. 1
Why Other Tests Are Inappropriate as Initial Studies
Barium swallow: While biphasic esophagram has 96% sensitivity for esophageal cancer, it cannot provide tissue diagnosis or definitively exclude eosinophilic esophagitis. 1 Barium studies are more appropriate after structural abnormalities have been excluded by endoscopy, particularly for evaluating motility disorders. 1
CT chest: Does not assess esophageal mucosa and motility adequately and is not indicated as initial imaging. 1 CT may be helpful in subsequent evaluation if initial studies are unrevealing. 1
24-hour pH monitoring: Indicated after normal endoscopy findings and when evaluating PPI treatment failures, not as the initial diagnostic test when alarm features are present. 1
Critical Pitfalls to Avoid
Failing to recognize weight loss and dysphagia as alarm features requiring immediate endoscopic evaluation can lead to delayed cancer diagnosis. 1
Overlooking eosinophilic esophagitis by not obtaining adequate esophageal biopsies during endoscopy. 1
Proceeding directly to motility studies or pH monitoring without first excluding structural pathology in patients with alarm symptoms. 1
Question 2: Immediate Management for Post-Gastric Banding Complications
NGT with suction is the immediate management for a patient presenting with vomiting and abdominal distension after gastric banding surgery.
Initial Conservative Management Approach
Nasogastric tube decompression with suction is the first-line immediate intervention for suspected gastric outlet obstruction or pouch dilatation following bariatric surgery.
This allows gastric decompression, relieves symptoms, and provides time for diagnostic evaluation before proceeding to more invasive interventions.
Most post-banding complications including band slippage, pouch dilatation, and gastric outlet obstruction can be initially managed conservatively with NGT decompression while planning definitive treatment.
Diagnostic Evaluation After Initial Stabilization
Following NGT placement, urgent upper GI contrast study or endoscopy should be performed to identify the specific complication (band slippage, pouch herniation, or stenosis). 2
Esophageal and gastric pouch dilatations are not uncommon after laparoscopic adjustable gastric banding, and most cases are initially treated by gastric band deflation or removal after stabilization. 2
Why Other Options Are Not Immediate Management
Endoscopy: While important for diagnosis, it should not be the immediate first step in an acutely obstructed patient with distension, as it carries risk of perforation in a distended stomach. Decompression first is safer.
Laparotomy: Too aggressive as immediate management without first attempting conservative decompression and diagnostic evaluation. Reserved for cases with perforation, ischemia, or failure of conservative management.
Partial gastrectomy: Not an immediate management option; this would only be considered after failed conservative measures and proper diagnostic workup showing irreversible complications.
Clinical Pearls
Severe dysphagia can persist despite gastric band removal in some cases due to scar stenosis or gastric pouch herniation into the thorax, requiring subsequent surgical intervention. 2
The immediate priority is gastric decompression to prevent aspiration and allow for safe diagnostic evaluation before definitive treatment decisions.