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USMLE® Step 2 Question of the Day: Difficulty swallowing

Osmosis Team
Jun 12, 2024

Learn about the USMLE Step 2 CK diagnostic approach through the case of a 67-year-old man with progressive dysphagia, weight loss, hoarseness, and chest pain. This scenario highlights the importance of selecting appropriate tests and integrating clinical findings to confirm a diagnosis and guide treatment.


A 67-year-old man presents to the clinic for evaluation of difficulty swallowing that began with solids and has progressed to liquids over the past three months. Additionally, he reports a recent onset of voice hoarseness and chest pain when eating. He has unintentionally lost 10 kg (22 lbs) during the past three months. He has no significant past medical history. He has a 40-pack year smoking history and consumes 3 drinks of alcohol approximately 5 nights a week. BMI is 21 kg/m2. Temperature is 36.8°C (98.2°F), heart rate is 88/min, blood pressure is 135/85 mm Hg, respiratory rate is 16/min, and oxygen saturation is 97% on room air. He appears pale and thin. There is no palpable lymphadenopathy in the neck. Cardiopulmonary and abdominal examinations are unremarkable. Which of the following tests should be ordered next to help make a diagnosis? 

A. Esophagogastroduodenoscopy (EGD) with biopsies

B. Barium swallow study

C. Contrast-enhanced computed tomography (CT) of the chest and abdomen  

D. Esophageal manometry

E. 24-hour pH monitoring 

Scroll down for the correct answer!

The correct answer to today's USMLE® Step 2 CK Question is...

A. Esophagogastroduodenoscopy (EGD) with biopsies

Before we get to the Main Explanation, let's see why the answer wasn't B, C, D, or E. Skip to the bottom if you want to see the correct answer right away!

Incorrect answer explanations

Today's incorrect answers are...

B. Barium swallow study 

Incorrect: This patient is suspected of having esophageal cancer. A barium swallow can delineate structural abnormalities of the esophagus but lacks specificity and is not able to provide a histological diagnosis. It may be useful in the initial evaluation of dysphagia but is not the best next step in suspected esophageal cancer.

C. Contrast-enhanced computed tomography (CT) of the chest and abdomen

Incorrect: While a CT scan of the chest and abdomen is part of the staging for esophageal cancer, particularly for assessing metastasis, it does not provide a definitive diagnosis or histological classification. 

D. Esophageal manometry

Incorrect: Esophageal manometry is used for diagnosing motility disorders, which typically cause dysphagia in both solids and liquids from the start, unlike this patient’s progressive dysphagia. Given his clinical presentation and risk factors, esophageal cancer is more likely, and should be diagnosed with EGD with biopsies. 

E. 24-hour pH monitoring 

Incorrect: This test evaluates for gastroesophageal reflux disease, which can be a precursor to adenocarcinoma, but it cannot make a histological diagnosis of esophageal cancer. This patient’s symptoms suggest esophageal cancer and EGD with biopsies is necessary for diagnosis. 

Main Explanation

This patient presents with progressive dysphagia, unintentional weight loss, voice hoarseness, and a history of smoking and excessive alcohol use. Progressive dysphagia, progressing from dysphagia with solids to dysphagia with liquids can be seen in esophageal cancer as the lumen narrows due to a growing tumor.  When esophageal cancer is suspected, esophagogastroduodenoscopy (EGD) with biopsies should be performed to confirm the diagnosis. 

EGD with biopsy, allows for direct visualization of the esophagus, assessment of tumor extent, and tissue sampling for histological evaluation. Histopathology will differentiate between the two main types of esophageal cancer: adenocarcinoma and squamous cell carcinomaAdenocarcinoma, often located in the distal esophagus, is commonly associated with gastroesophageal reflux disease (GERD), and Barrett esophagus. In contrast, squamous cell carcinoma typically arises in the upper and middle esophagus and is strongly linked to smoking and alcohol use.  

Following diagnosis, staging should be done with contrast-enhanced computed tomography (CT) scans of the chest and abdomen (+/- pelvis) to assess for local invasion and distant metastases. Endoscopic ultrasound is used to evaluate tumor depth and nearby lymph node involvement, and a PET scan may be performed to assess for metastatic disease. Accurate staging is crucial for determining the appropriate treatment, which may vary significantly based on the stage and histological subtype.

Major takeaway

Esophageal cancer should be suspected in patients with progressive dysphagia, weight loss, and odynophagia. Esophagogastroduodenoscopy (EGD) with biopsies should be performed to confirm the diagnosis. 

References

Ajani JA, D'Amico TA, Bentrem DJ, et al. Esophageal and Esophagogastric Junction Cancers, Version 2.2023, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. 2023;21(4):393-422. doi:10.6004/jnccn.2023.0019 

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