What is the best diagnostic approach for a patient with dull chest pain that worsens with spicy meals, emotional stress, and when lying flat, suggestive of gastroesophageal reflux disease (GERD)?

Diagnostic Approach for GERD-Related Chest Pain

After cardiac causes have been excluded, upper endoscopy (Option B) is the recommended initial diagnostic test for this patient with suspected GERD-related chest pain. 1

Clinical Reasoning

The clinical presentation strongly suggests gastroesophageal reflux disease as the underlying cause:

• Pain worsened after spicy meals, lying flat, and with emotional stress are characteristic features of GERD, which is the most likely cause for recurring unexplained chest pain of esophageal origin 2, 1
• The dull, non-exertional nature of the pain that increases in the supine position further supports an esophageal rather than cardiac etiology 2

Why Endoscopy First

Upper endoscopy should be the initial diagnostic test when an esophageal cause of chest pain is suspected because it provides direct visualization and allows for tissue diagnosis 2, 1:

• Endoscopy directly visualizes esophageal mucosa to identify erosive esophagitis, strictures, or Barrett's esophagus, and obtains tissue biopsies to detect microscopic inflammation that may not be visible to the naked eye 1
• Approximately 25% of patients have histologic evidence of esophageal inflammation that cannot be detected without biopsy 3
• Endoscopy can identify alternative upper gastrointestinal diagnoses and exclude conditions that mimic GERD, such as eosinophilic esophagitis 2, 3

Why Not the Other Options

Barium swallow (Option A) has limited diagnostic value for GERD:

• Barium studies can demonstrate reflux in more than 25% of asymptomatic patients, making it non-specific 4
• It is most useful only for demonstrating structural abnormalities such as strictures and hiatal hernia, not for diagnosing GERD itself 4

Esophageal manometry (Option C) is reserved for later evaluation:

• Manometry should be performed after normal endoscopy when symptoms persist despite acid suppression therapy 2, 1
• Its primary role is to identify esophageal motility disorders and to document preserved peristaltic function before anti-reflux surgery 2
• There is poor correlation between lower esophageal sphincter pressure and reflux esophagitis 4

pH monitoring (Option D) is the third-line diagnostic test:

• pH monitoring should be performed after both normal endoscopy and manometry, when the diagnosis remains uncertain 2, 1
• It is most useful when determining if there is excessive esophageal acid exposure in patients being considered for anti-reflux surgery 2
• pH monitoring does not assess for esophageal mucosal injury and cannot exclude conditions like eosinophilic esophagitis 3

Critical Diagnostic Algorithm

The proper sequence after excluding cardiac causes is 2, 1:

1. First: Upper endoscopy with biopsy to visualize mucosa and obtain tissue diagnosis
2. Second: Esophageal manometry if endoscopy is normal but symptoms persist despite PPI therapy
3. Third: pH monitoring if both endoscopy and manometry are normal and diagnosis remains uncertain

Important Clinical Pitfalls

• Symptoms are not sufficiently specific to be fully diagnostic, as they overlap extensively between GERD, gastritis, esophagitis, and peptic ulcer disease 2, 1
• Empiric PPI trials have poor diagnostic performance (sensitivity 71-78%, specificity 41-54%) and should not be relied upon as a diagnostic test—lack of response does not rule out GERD, and response does not confirm it due to placebo effects 3
• Relief with antacids or antisecretory agents is suggestive but not diagnostic of GERD 1

Alternative Approach When Endoscopy Unavailable

If endoscopy cannot be performed immediately and alarm features (dysphagia, odynophagia, gastrointestinal bleeding, unexplained anemia, weight loss, recurrent vomiting) are absent 2:

• A trial of empiric twice-daily PPI therapy is reasonable as both a diagnostic and therapeutic intervention, but only after cardiac etiology has been carefully excluded 2, 1
• However, this approach should not replace definitive endoscopic evaluation, which remains the gold standard 1