Why is a computed tomography (CT) scan of the neck and chest required before an esophagogastroduodenoscopy (OGD) in a 54-year-old patient presenting with epigastric pain and dysphagia?

From the Guidelines

In a 54-year-old patient with epigastric pain and dysphagia, a CT scan of the neck and chest is required before an esophagogastroduodenoscopy (OGD) to rule out potentially serious structural abnormalities that could explain the symptoms or complicate the endoscopic procedure. This recommendation is based on the most recent and highest quality study available, which emphasizes the importance of comprehensive imaging in patients with concerning symptoms 1. The combination of dysphagia with epigastric pain in a middle-aged individual raises concern for malignancy, and CT imaging can detect wall thickening, masses, lymphadenopathy, or metastatic disease that might alter management decisions.

Key Considerations

• The American College of Radiology (ACR) Appropriateness Criteria suggest that CT neck and chest with IV contrast may be appropriate for the initial imaging of oropharyngeal or retrosternal dysphagia in certain scenarios, particularly when there are concerns for structural abnormalities or malignancy 1.
• CT imaging can identify conditions such as esophageal cancer, extrinsic compression from mediastinal masses, vascular rings, or aortic aneurysms that may not be safely or adequately assessed by endoscopy alone.
• The imaging findings may guide the endoscopist regarding the safety of the procedure, the need for specific biopsy sites, or whether alternative approaches might be necessary.

Clinical Implications

• The presence of epigastric pain and dysphagia in a 54-year-old patient warrants a thorough evaluation to rule out serious underlying conditions.
• A CT scan of the neck and chest can provide valuable information about the esophagus, stomach, and surrounding structures, which can inform the decision to proceed with OGD and guide the endoscopic procedure.
• The sequential approach of imaging before endoscopy ensures comprehensive evaluation and safer procedural planning in patients with concerning symptoms, ultimately prioritizing morbidity, mortality, and quality of life outcomes.

From the Research

Importance of CT Neck and Chest before OGD

In a 54-year-old patient presenting with epigastric pain and dysphagia, a CT scan of the neck and chest is required before undergoing an esophagogastroduodenoscopy (OGD) for several reasons:

• Detection of esophageal abnormalities: CT imaging can help identify various esophageal pathologies, including infectious, inflammatory, congenital, structural, or neoplastic disorders 2.
• Evaluation of dysphagia: Dysphagia can be caused by obstructive symptoms that may seem to originate in the throat or neck but are actually caused by distal esophageal lesions 3.
• Assessment of epigastric pain: Epigastric pain has a broad differential diagnosis, including cardiac causes, serious intra-abdominal causes, acute pancreatitis, esophageal emergencies, and peptic ulcer disease/gastritis 4.
• Identification of potential complications: In patients with a history of laparoscopic adjustable gastric band (LAGB) placement, CT scans can help diagnose complications such as esophageal erosion of the gastric band 5.

Diagnostic Approach

The diagnostic approach to dysphagia and epigastric pain involves:

• A detailed history
• Endoscopy to evaluate for structural abnormalities, including malignancy
• Esophageal biopsies to diagnose conditions such as eosinophilic esophagitis
• High-resolution manometry (HRM) and the Chicago Classification to diagnose esophageal motility disorders
• Functional lumen imaging probe (FLIP) to measure esophageal distensibility and identify motility abnormalities 6.