Endoscopy is the Best Initial Diagnostic Test
For this patient presenting with dull chest pain exacerbated by spicy meals, emotional stress, lying flat, and anemia (Hb 110), upper endoscopy with biopsy should be performed first to establish the diagnosis. 1
Rationale for Endoscopy as First-Line Test
The combination of alarm features in this patient mandates immediate endoscopic evaluation:
Weight loss and anemia are alarm features that require urgent endoscopy to exclude esophageal or gastric malignancy, as these symptoms have the best performance characteristics for identifying upper GI malignancies 1
Dysphagia-like symptoms (pain with meals, positional worsening) combined with anemia necessitate direct mucosal visualization rather than functional testing 1
The American College of Gastroenterology specifically recommends endoscopy with biopsy as the best diagnostic test for patients presenting with central chest pain, dysphagia, and alarm features like anemia 1
Why Other Tests Are Inappropriate Initially
Barium Swallow (Option A)
- Barium studies are more appropriate after structural abnormalities have been excluded by endoscopy, particularly for evaluating motility disorders 1
- While biphasic esophagram has 96% sensitivity for esophageal cancer, it cannot provide tissue diagnosis or definitively exclude eosinophilic esophagitis 1
- The ACR guidelines state there is no relevant literature supporting barium swallow as an initial test for acute nonspecific chest pain 2
Esophageal Manometry (Option C)
- Manometry evaluates motility disorders but cannot diagnose structural pathology or mucosal disease 2
- Proceeding directly to motility studies without first excluding structural pathology in patients with alarm symptoms is explicitly advised against 1
- This test would be appropriate only after endoscopy rules out structural causes 2
pH Monitoring (Option D)
- pH monitoring is indicated after normal endoscopy findings and when evaluating PPI treatment failures, not as the initial diagnostic test when alarm features are present 1, 3
- This functional test cannot diagnose the structural causes (malignancy, esophagitis, strictures) that must be excluded first 3
Critical Endoscopic Protocol
When performing endoscopy in this patient:
Obtain multiple esophageal mucosal biopsies (preferably at least 5 specimens) to evaluate for eosinophilic esophagitis, which can present with similar symptoms and may be missed on visual inspection alone 1
Evaluate for erosive esophagitis, Barrett's esophagus, malignancy, and infectious causes 4
Endoscopy is highly accurate for esophageal cancer when multiple biopsy specimens and brushings are obtained 1
Common Pitfalls to Avoid
Failing to recognize anemia as an alarm feature requiring immediate endoscopic evaluation can lead to delayed cancer diagnosis 1
Overlooking eosinophilic esophagitis by not obtaining adequate esophageal biopsies during endoscopy 1
Attributing symptoms to GERD and starting empiric PPI therapy without first excluding malignancy in the presence of anemia 3