A physician-validated, board-style question from the Active Transport QBank. Try it, then check the reasoning for every option.
A 55-year-old man presents to his primary care physician for trouble swallowing. The patient claims that he used to struggle when eating food if he did not chew it thoroughly, but now he occasionally struggles with liquids as well. He also complains of a retrosternal burning sensation whenever he eats. He also claims that he feels his throat burns when he lays down or goes to bed. Otherwise, the patient has no other complaints. The patient has a past medical history of obesity, diabetes, constipation, and anxiety. His current medications include insulin, metformin, and lisinopril. On review of systems, the patient endorses a 5 pound weight loss recently. The patient has a 22 pack-year smoking history and drinks alcohol with dinner. His temperature is 99.5°F (37.5°C), blood pressure is 177/98 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air. On physical exam, you note an overweight man in no current distress. Abdominal exam is within normal limits. Which of the following is the best next step in management?
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A
Barium swallowIncorrect. Barium swallow is best for suspected motility disorders or Zenker diverticulum; it can miss small mucosal cancers and does not allow biopsy, which this alarm-feature patient requires.
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B
EndoscopyCorrect. Progressive dysphagia plus weight loss in a smoker with chronic reflux mandates EGD to directly visualize and biopsy the esophagus, ruling out Barrett esophagus and adenocarcinoma.
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C
ManometryIncorrect. Manometry evaluates esophageal motility (e.g., achalasia, diffuse esophageal spasm) and is performed only after endoscopy excludes a structural lesion.
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D
Omeprazole trialIncorrect. An empiric PPI trial is acceptable for uncomplicated GERD; alarm features (weight loss, progressive dysphagia, smoking, age) make empiric treatment without endoscopy inappropriate.
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E
24-hour pH monitoringIncorrect. Ambulatory pH monitoring quantifies acid reflux but does not visualize mucosal lesions or allow biopsy — alarm features (weight loss, progressive dysphagia, smoking) mandate direct visualization with EGD.
↑ Tap an answer to reveal the reasoning
Answer: B. This middle-aged smoker with progressive dysphagia (initially solids, now also liquids), retrosternal burning, nocturnal acid regurgitation, and unintentional weight loss has multiple red flags for esophageal malignancy superimposed on chronic GERD. Long-standing reflux predisposes to Barrett esophagus and esophageal adenocarcinoma, and his smoking history compounds the risk. Whenever dysphagia is accompanied by any alarm feature — weight loss, anemia, age >55, hematemesis, or odynophagia — empiric acid suppression is inappropriate; tissue must be obtained.
Upper endoscopy (EGD) is the single best next test because it allows direct mucosal visualization, biopsy of any suspicious lesion (to rule out adenocarcinoma or Barrett metaplasia), and assessment for strictures or erosive esophagitis. Barium swallow is a reasonable initial study only when motility disorders such as achalasia or Zenker diverticulum are strongly suspected; here the picture is structural/neoplastic, and barium would miss small mucosal cancers. Manometry is reserved for cases where endoscopy is unrevealing and a motility disorder remains on the differential. An omeprazole trial is appropriate only for uncomplicated GERD without alarm features — this patient has several.
Clinical pearl: dysphagia that progresses from solids to liquids over months in an older smoker is mechanical obstruction (cancer or stricture) until proven otherwise — endoscope first.
**Why each option:**
**A.** Barium swallow is best for suspected motility disorders or Zenker diverticulum; it can miss small mucosal cancers and does not allow biopsy, which this alarm-feature patient requires.
**B.** Correct. Progressive dysphagia plus weight loss in a smoker with chronic reflux mandates EGD to directly visualize and biopsy the esophagus, ruling out Barrett esophagus and adenocarcinoma.
**C.** Manometry evaluates esophageal motility (e.g., achalasia, diffuse esophageal spasm) and is performed only after endoscopy excludes a structural lesion.
**D.** An empiric PPI trial is acceptable for uncomplicated GERD; alarm features (weight loss, progressive dysphagia, smoking, age) make empiric treatment without endoscopy inappropriate.