Case 8: Diagnostic Testing

Here are the initial lab results:

Further diagnostic testing

Choose the two diagnostic tests that would be most appropriate to obtain next.
Upper Endoscopy
Excellent choice. The patient has a food impaction with inability to tolerate his oral secretions and hence an urgent endoscopy within 12 hours of presentation is warranted to minimize the chance of esophageal ischemia. Upper endoscopy will also allow for inspection of the esophagus for structural abnormalities and tissue biopsies for histologic analysis.
Barium Swallow
This isn’t an appropriate next test. While a barium swallow can reveal structural abnormalities of the esophagus such as rings and also demonstrate findings of motility disorders such as achalasia, the patient has a food impaction with inability to handle his secretions and warrants urgent upper endoscopy. Swallowing contrast with complete esophageal obstruction would also be contraindicated as this could lead to aspiration. Try again!
Esophageal Manometry
This isn’t an appropriate next test. The patient does not have symptoms of an esophageal motility disorder, namely evidenced by dysphagia to both solids and liquids. He warrants an urgent upper endoscopy to treat the food impaction.
CT Neck and Chest
This isn’t an appropriate next test. CT is a poor imaging test to elucidate structural abnormalities of the esophagus. Moreover, the mucosa and mucosal histology cannot be assessed.
X-Ray Chest
Good choice. In patients with suspected food impaction a chest xray can help reveal features of esophageal microperforation such as mediastinal free air which would alter the management approach to the case.

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Case 8 Index:
Physical Exam
Differential Diagnosis

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