What is the most appropriate initial diagnostic step for a younger to middle-aged adult patient presenting with dull chest pain unrelated to activity, worsened by spicy meals or emotional stress, and exacerbated by lying flat?

Diagnostic Approach for Suspected GERD-Related Chest Pain

Direct Answer

After excluding cardiac causes, upper endoscopy (Option B) is the most appropriate initial diagnostic test for this patient with chest pain worsened by spicy meals, lying flat, and emotional stress. 1

Algorithmic Diagnostic Approach

Step 1: Exclude Cardiac Causes First (Mandatory)

Before pursuing any gastrointestinal workup, cardiac evaluation must be completed because GERD-related chest pain can mimic myocardial ischemia. 1, 2

Required initial cardiac assessment:

• 12-lead ECG within 10 minutes of presentation 3, 2
• Cardiac troponin measurement as soon as possible 2
• Focused cardiovascular examination looking for diaphoresis, tachycardia, hypotension, or new murmurs 2

However, this patient's presentation strongly suggests noncardiac origin: Sharp chest pain that increases with lying supine is unlikely related to ischemic heart disease. 3 Pain worsened after meals, exacerbation with lying flat, and association with emotional stress suggest gastroesophageal reflux disease as the most likely cause. 1

Step 2: Upper Endoscopy as First-Line Diagnostic Test

Once cardiac causes are excluded, upper endoscopy should be the initial diagnostic test when esophageal chest pain is suspected. 3, 1 This recommendation has strength of evidence level A from the American College of Cardiology and American Heart Association. 1

Why endoscopy is the correct choice:

• Directly visualizes esophageal mucosa to identify erosive esophagitis, strictures, or Barrett's esophagus 1
• Obtains tissue biopsies to detect microscopic inflammation or eosinophilic esophagitis 3, 1
• Identifies structural abnormalities that other tests cannot detect 3

Step 3: When to Use Other Diagnostic Tests

Esophageal manometry (Option C) is reserved as a second-line test after normal endoscopy when symptoms persist despite acid suppression therapy, specifically to identify esophageal motility disorders like achalasia or distal esophageal spasm. 3, 1

pH monitoring (Option D) is performed as the third diagnostic step after both normal endoscopy and manometry, most useful when GERD diagnosis remains uncertain in patients with atypical symptoms but no alarm features. 1

Barium swallow (Option A) has no supporting literature for use as an initial imaging test in acute nonspecific chest pain evaluation. 3 While it can detect anatomic causes like hiatal hernia or demonstrate gastroesophageal reflux, it is not recommended as first-line. 3

Critical Clinical Pitfalls to Avoid

Do not rely on symptom response alone: Symptoms are nonspecific and overlap extensively between GERD, gastritis, esophagitis, and peptic ulcer disease. Relief with antacids or antisecretory agents is suggestive but not sufficiently specific to be fully diagnostic. 3, 1

Do not use empiric PPI trials as a diagnostic test: Empiric PPI trials have poor diagnostic performance and should not be relied upon as a diagnostic test according to the American Gastroenterological Association. 1 However, if endoscopy cannot be performed immediately and alarm features are absent, a trial of empiric twice-daily PPI therapy is reasonable only after cardiac etiology has been carefully excluded. 1

Do not assume nitroglycerin response indicates cardiac origin: Esophageal spasm also responds to nitroglycerin, making this an unreliable diagnostic tool. 2, 4

Alternative Management Path

If the patient has no alarm features (dysphagia, odynophagia, gastrointestinal bleeding, unexplained iron deficiency anemia, weight loss, or recurrent vomiting), a trial of empiric acid suppression therapy may be considered before endoscopy. 3 However, if symptoms persist despite acid suppression, endoscopy becomes mandatory. 3