A 52-year-old man is evaluated for dysphagia of 3 months' duration. He reports regurgitating undigested food soon after eating solid food, occasional coughing and choking after swallowing, and chronic halitosis. He reports no weight loss or chest pain. He drinks two beers weekly and does not smoke.
On physical examination, vital signs are normal; BMI is 25. The remainder of the examination, including abdominal examination, is unremarkable.
Which of the following is the most appropriate diagnostic test to perform next?
A. Barium esophagography
B. Esophageal manometry
C. 24-Hour esophageal pH monitoring
D. Upper endoscopy
MKSAP Answer and Critique
The correct answer is A. Barium esophagography. This content is available to MKSAP 18 subscribers as Question 7 in the Gastroenterology and Hepatology section. More information about MKSAP is available online.
Barium esophagram is the most appropriate next diagnostic test for this patient. The patient's primary symptom of dysphagia associated with regurgitation of undigested food is the classic presentation of a Zenker diverticulum. Other commonly reported symptoms include halitosis, aspiration, and gurgling in the chest, but esophageal dysphagia is the most common symptom, reported by the majority of patients with a Zenker diverticulum. This type of diverticulum is located in the cervical esophagus and may lead to complications such as aspiration and pneumonia. The best initial test is a barium esophagram, which will identify the diverticulum. Treatment is reserved for symptomatic patients and endoscopic diverticulectomy is favored where surgical expertise is available. In medical centers without such expertise, surgery by external neck incision is used.
Esophageal manometry is used when there is concern for a motility disorder, such as achalasia. Patients with motility disorders commonly report dysphagia to liquids or both solids and liquids; this patient's dysphagia to solid food does not suggest a motility disorder.
Ambulatory pH testing and impedance-pH testing can be valuable tools in identifying acid exposure within the esophagus. Impedance-pH testing can identify both acid and nonacid reflux. Testing can be done with a 48-hour wireless capsule or 24-hour transnasal catheter to detect active acid reflux. The wireless capsule has been shown to have better patient tolerability. A 24-hour pH manometry test is often used to further evaluate a patient with symptoms of gastroesophageal reflux disease that have not responded to medical therapy (usually a trial of an acid-reducing agent such as a proton pump inhibitor). A peptic stricture causing solid-food dysphagia may result from untreated reflux, but this patient reports dysphagia and regurgitation of undigested food, symptoms strongly suggestive of Zenker diverticulum.
Endoscopy is used to inspect the mucosal surface of the esophagus, stomach, and duodenum to identify conditions within the upper gastrointestinal tract. Because this patient's symptoms are consistent with the presentation of a Zenker diverticulum, a barium esophagram is a more appropriate choice than upper endoscopy. Although endoscopy may identify the diverticulum, there is risk for perforation if the endoscope enters the diverticulum.
- Patients with dysphagia associated with regurgitation of undigested food should be evaluated with a barium esophagram for the presence of a Zenker diverticulum.