GERD and esophageal disorders US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for GERD and esophageal disorders. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
GERD and esophageal disorders US Medical PG Question 1: A scientist is studying the mechanism by which the gastrointestinal system coordinates the process of food digestion. Specifically, she is interested in how distension of the lower esophagus by a bolus of food changes responses in the downstream segments of the digestive system. She observes that there is a resulting relaxation and opening of the lower esophageal (cardiac) sphincter after the introduction of a food bolus. She also observes a simultaneous relaxation of the orad stomach during this time. Which of the following substances is most likely involved in the process being observed here?
- A. Neuropeptide-Y
- B. Secretin
- C. Ghrelin
- D. Vasoactive intestinal polypeptide (Correct Answer)
- E. Motilin
GERD and esophageal disorders Explanation: ***Vasoactive intestinal polypeptide***
- **VIP (Vasoactive intestinal polypeptide)** is a neuropeptide that mediates **relaxation** of the **smooth muscle** in the gastrointestinal tract, including the **lower esophageal sphincter** and the **orad stomach**, facilitating the passage of food.
- This relaxation is part of the **receptive relaxation** process, allowing the stomach to accommodate food without a significant increase in intragastric pressure.
*Neuropeptide-Y*
- **Neuropeptide-Y (NPY)** is primarily involved in stimulating **food intake** and **reducing energy expenditure**, acting as an orexigenic peptide.
- It does not directly mediate the relaxation of the **lower esophageal sphincter** or **orad stomach** in response to food bolus distension.
*Secretin*
- **Secretin** is a hormone released in response to **acid in the duodenum** and primarily stimulates the pancreas to release **bicarbonate-rich fluid**.
- Its main role is to neutralize stomach acid, not to mediate sphincter relaxation or stomach accommodation.
*Ghrelin*
- **Ghrelin** is known as the "**hunger hormone**" and primarily stimulates **appetite** and **growth hormone release**.
- It does not play a direct role in the relaxation of the **lower esophageal sphincter** or **orad stomach** during swallowing.
*Motilin*
- **Motilin** promotes **gastric and intestinal motility** during the **interdigestive phase**, responsible for the migrating motor complex (MMC).
- Its actions are generally prokinetic, rather than causing relaxation of the upper GI tract in response to a food bolus.
GERD and esophageal disorders US Medical PG Question 2: A 62-year-old man comes to the office complaining of dysphagia that started 4-5 months ago. He reports that he initially had difficulty swallowing only solid foods. More recently, he has noticed some trouble swallowing liquids. The patient also complains of fatigue, a chronic cough that worsens at night, and burning chest pain that occurs after he eats. He says that he has used over-the-counter antacids for "years" with mild relief. He denies any change in diet, but says he has "gone down a pant size or 2." The patient has hypertension and hyperlipidemia. He takes amlodipine and atorvastatin. He smoked 1 pack of cigarettes a day for 12 years while in the military but quit 35 years ago. He drinks 1-2 beers on the weekend while he is golfing with his friends. His diet consists mostly of pasta, pizza, and steak. The patient's temperature is 98°F (36.7°C), blood pressure is 143/91 mmHg, and pulse is 80/min. His BMI is 32 kg/m^2. Physical examination reveals an obese man in no acute distress. No masses or enlarged lymph nodes are appreciated upon palpation of the neck. Cardiopulmonary examination is unremarkable. An endoscopy is performed, which identifies a lower esophageal mass. Which of the following is the most likely diagnosis?
- A. Nutcracker esophagus
- B. Plummer-Vinson syndrome
- C. Small cell carcinoma
- D. Adenocarcinoma (Correct Answer)
- E. Squamous cell carcinoma
GERD and esophageal disorders Explanation: ***Adenocarcinoma***
- The patient's history of **dysphagia progressing from solids to liquids**, **weight loss**, and **long-standing GERD symptoms** (chronic cough, burning chest pain, use of antacids for years) are highly suggestive of **esophageal adenocarcinoma**, especially given the endoscopic finding of a **lower esophageal mass**.
- **Risk factors** present include **obesity** (BMI 32 kg/m²), **chronic GERD**, and a remote history of smoking, which contribute to the development of **Barrett's esophagus**, a precursor to adenocarcinoma.
- Adenocarcinoma typically arises in the **distal/lower esophagus** due to chronic acid reflux.
*Nutcracker esophagus*
- Characterized by **high-amplitude peristaltic contractions** of the esophagus, primarily causing **chest pain** and **dysphagia**.
- It is a **motility disorder**, not a structural lesion, and does not present with **progressive dysphagia from solids to liquids**, **weight loss**, or an **esophageal mass** on endoscopy.
*Plummer-Vinson syndrome*
- A rare condition characterized by the triad of **iron deficiency anemia**, **dysphagia**, and **esophageal webs** (typically in the upper esophagus).
- While it causes dysphagia, it does not present with an **esophageal mass**, **weight loss**, or a history of long-standing GERD.
- More common in middle-aged women and associated with increased risk of squamous cell carcinoma.
*Small cell carcinoma*
- **Small cell carcinoma** is primarily a type of **lung cancer**, although it can rarely occur in the esophagus.
- Esophageal small cell carcinoma is **very aggressive** and usually presents with symptoms similar to other esophageal cancers but is **much less common** than adenocarcinoma or squamous cell carcinoma in the esophagus.
*Squamous cell carcinoma*
- **Squamous cell carcinoma** of the esophagus is strongly associated with **smoking** and **alcohol use**, and typically arises in the **upper or middle esophagus**.
- While the patient has a remote smoking history, his **long-standing GERD**, **obesity**, and **lower esophageal mass** location make **adenocarcinoma** the more probable diagnosis, as adenocarcinoma arises from **Barrett's esophagus** in the distal esophagus due to chronic reflux.
GERD and esophageal disorders US Medical PG Question 3: A 45-year-old man presents to the emergency department with difficulties swallowing food. He states that he experiences pain when he attempts to swallow his medications or when he drinks water. He reveals that he was diagnosed with HIV infection five years ago. He asserts that he has been taking his antiretroviral regimen, including emtricitabine, rilpivirine, and tenofovir. His temperature is 98°F (37°C), blood pressure is 100/60 mmHg, pulse is 90/min, respirations are 22/min, and oxygen saturation is 99% on room air. His physical exam is notable for a clear oropharynx, no lymphadenopathy, and a normal cardiac and pulmonary exam. No rashes are noted throughout his body. His laboratory results are displayed below:
Hemoglobin: 12 g/dL
Hematocrit: 37 %
Leukocyte count: 8,000/mm^3 with normal differential
Platelet count: 160,000/mm^3
Serum:
Na+: 138 mEq/L
Cl-: 108 mEq/L
K+: 3.5 mEq/L
HCO3-: 26 mEq/L
BUN: 35 mg/dL
Glucose: 108 mg/dL
Creatinine: 1.1 mg/dL
CD4+ count: 90/mm^3
HIV viral load: 59,000 copies/mL
What is the best next step in management?
- A. Fluconazole (Correct Answer)
- B. Nystatin
- C. Oral swab and microscopy
- D. Methylprednisolone
- E. Esophageal endoscopy and biopsy
GERD and esophageal disorders Explanation: ***Fluconazole***
- The patient's **odynophagia**, low **CD4+ count**, and high **HIV viral load** are highly suggestive of **esophageal candidiasis**.
- **Fluconazole** is the initial empiric treatment of choice for suspected esophageal candidiasis in HIV-positive patients, given its high efficacy and good tolerability.
*Nystatin*
- **Nystatin** is typically used for **oral candidiasis (thrush)**, which presents with white plaques in the mouth.
- The patient has a **clear oropharynx** and **odynophagia**, indicating esophageal involvement, for which nystatin is less effective.
*Oral swab and microscopy*
- While an **oral swab** can confirm oral candidiasis, it is not sufficient for diagnosing **esophageal candidiasis**.
- Given the patient's symptoms of odynophagia and high clinical suspicion in an immunocompromised patient, empiric treatment is preferred over initial diagnostic testing for uncomplicated esophageal candidiasis.
*Methylprednisolone*
- **Methylprednisolone** is a corticosteroid used to reduce inflammation and is not indicated for the treatment of **candidal infections**.
- Using corticosteroids in an immunocompromised patient with an active opportunistic infection could worsen his condition.
*Esophageal endoscopy and biopsy*
- **Esophageal endoscopy and biopsy** are typically reserved for patients who **fail empiric antifungal therapy** or present with **atypical symptoms** not consistent with candidiasis.
- Given the clear clinical picture, initial empiric treatment with fluconazole is the standard first step.
GERD and esophageal disorders US Medical PG Question 4: A 27-year-old woman presents with painful swallowing for the past 2 days. She received a kidney transplant 3 months ago for lupus-induced end-stage renal disease. She takes tacrolimus, mycophenolate mofetil, prednisone, and calcium supplements. The blood pressure is 120/80 mm Hg, the pulse is 72/min, the respirations are 14/min, and the temperature is 38.0°C (100.4°F). Esophagoscopy shows serpiginous ulcers in the distal esophagus with normal surrounding mucosa. Biopsy shows large cytoplasmic inclusion bodies. Which of the following is the most appropriate pharmacotherapy at this time?
- A. Ganciclovir (Correct Answer)
- B. Budesonide
- C. No pharmacotherapy at this time
- D. Fluconazole
- E. Pantoprazole
GERD and esophageal disorders Explanation: ***Ganciclovir***
- The patient's presentation with **painful swallowing**, **serpiginous ulcers in the distal esophagus**, and **large cytoplasmic inclusion bodies** on biopsy, especially in an immunocompromised patient (kidney transplant recipient), is highly suggestive of **cytomegalovirus (CMV) esophagitis**.
- **Ganciclovir** is the first-line antiviral treatment for CMV infections, including esophagitis, particularly in transplant patients.
*Budesonide*
- **Budesonide** is a corticosteroid often used for inflammatory conditions like Crohn's disease or eosinophilic esophagitis.
- It is not indicated for viral infections and could potentially worsen the patient's immunocompromised state.
*No pharmacotherapy at this time*
- The patient has a clear symptomatic infection with characteristic findings (ulcers, inclusion bodies) in an immunocompromised state (post-transplant).
- Delaying treatment could lead to serious complications and dissemination of the CMV infection.
*Fluconazole*
- **Fluconazole** is an antifungal medication primarily used to treat *Candida* esophagitis, which typically presents with **linear, white plaques** and not serpiginous ulcers with cytoplasmic inclusion bodies.
- The biopsy findings rule out candidal infection, for which fluconazole would be appropriate.
*Pantoprazole*
- **Pantoprazole** is a proton pump inhibitor (PPI) used to reduce stomach acid, commonly prescribed for esophagitis due to reflux disease.
- While acid suppression can be part of supportive care, it does not address the underlying **viral etiology** of this patient's symptoms (CMV esophagitis).
GERD and esophageal disorders US Medical PG Question 5: A 56-year-old woman presents to her primary care physician complaining of heartburn, belching, and epigastric pain that is aggravated by coffee and fatty foods. She states that she has recently been having difficulty swallowing in addition to her usual symptoms. What is the most appropriate next step in management of this patient?
- A. Trial of an H2 receptor antagonist
- B. Trial of a proton pump inhibitor
- C. Upper endoscopy (Correct Answer)
- D. Nissen fundoplication
- E. Lifestyle changes - don't lie down after eating; avoid spicy foods; eat small servings
GERD and esophageal disorders Explanation: ***Upper endoscopy***
- The presence of **dysphagia** (difficulty swallowing) in a patient with chronic reflux symptoms is an **alarm symptom** that warrants immediate investigation to rule out serious conditions like **esophageal strictures** or **malignancy**.
- **Upper endoscopy** allows direct visualization of the esophagus, stomach, and duodenum, and enables biopsies if abnormalities are found.
*Trial of an H2 receptor antagonist*
- While H2 receptor antagonists can help manage reflux symptoms, they are generally prescribed for **mild to moderate GERD** without alarm symptoms.
- Starting this treatment without investigation could **delay diagnosis** of a potentially life-threatening condition given the dysphagia.
*Trial of a proton pump inhibitor*
- Proton pump inhibitors (PPIs) are highly effective for GERD symptoms and are often used as a first-line treatment for typical reflux.
- However, the presence of **dysphagia** is an **alarm symptom** that mandates further investigation with endoscopy before initiating or continuing empirical PPI therapy.
*Nissen fundoplication*
- **Nissen fundoplication** is a surgical procedure for severe GERD that is typically considered after **medical management has failed** and an **objective diagnosis** of GERD has been confirmed, often with endoscopy and pH monitoring.
- It is an **intervention**, not a diagnostic step, and would only be considered once the cause of dysphagia has been identified and ruled out for malignancy.
*Lifestyle changes - don't lie down after eating; avoid spicy foods; eat small servings*
- **Lifestyle modifications** are key components of GERD management and should be recommended to all patients with reflux symptoms.
- While beneficial, these changes alone are insufficient when an **alarm symptom** like dysphagia is present, as they would not address underlying structural issues or malignancy.
GERD and esophageal disorders US Medical PG Question 6: A 47-year-old man with gastroesophageal reflux disease comes to the physician because of severe burning chest pain and belching after meals. He has limited his caffeine intake and has been avoiding food close to bedtime. Esophagogastroduodenoscopy shows erythema and erosions in the distal esophagus. Which of the following is the mechanism of action of the most appropriate drug for this patient?
- A. Enhancement of the mucosal barrier
- B. Inhibition of ATPase (Correct Answer)
- C. Inhibition of H2 receptors
- D. Neutralization of gastric acid
- E. Inhibition of D2 receptors
GERD and esophageal disorders Explanation: **Inhibition of ATPase**
- The patient's symptoms (severe burning chest pain, belching after meals) and EGD findings (erythema and erosions in the distal esophagus) are classic for **Gastroesophageal Reflux Disease (GERD)**.
- The most effective treatment for GERD involves **proton pump inhibitors (PPIs)**, which work by irreversibly inhibiting the **H+/K+-ATPase** (proton pump) in the gastric parietal cells, thereby reducing acid secretion.
*Enhancement of the mucosal barrier*
- Medications that enhance the mucosal barrier, like **sucralfate**, provide a protective layer and are primarily used for stress ulcers or as an adjunct therapy, not as first-line treatment for erosive esophagitis.
- While beneficial, this mechanism does not directly address the *overproduction of acid* that is the primary cause of reflux and esophageal damage in GERD.
*Inhibition of H2 receptors*
- **H2-receptor blockers** (e.g., ranitidine, cimetidine) reduce acid secretion by blocking histamine's action on parietal cells, but they are generally less potent and effective than PPIs for healing erosive esophagitis.
- They tend to lose effectiveness over time due to **tachyphylaxis** and are often used for milder GERD symptoms or as maintenance therapy.
*Neutralization of gastric acid*
- **Antacids** (e.g., calcium carbonate, aluminum hydroxide) provide rapid, but temporary, relief by directly neutralizing existing stomach acid.
- They do not prevent acid production, making them unsuitable for managing persistent erosive esophagitis.
*Inhibition of D2 receptors*
- This mechanism is characteristic of **dopamine antagonists**, primarily used as antiemetics (e.g., metoclopramide) or antipsychotics (e.g., haloperidol).
- While metoclopramide can increase esophageal sphincter tone and gastric emptying, it is not the primary mechanism of action for the most effective drug in treating erosive esophagitis.
GERD and esophageal disorders US Medical PG Question 7: A 45-year-old African American male presents to his primary care physician complaining of difficulty swallowing that was initially limited to solids but has now progressed to liquids. Biopsy of the esophagus reveals dysplastic cells, but does not show evidence of glands or increased mucin. Which of the following most contributed to his condition?
- A. Gastroesophageal reflux disease
- B. Obesity
- C. Drinking extremely hot beverages
- D. Radiation exposure in the past 6 months
- E. Smoking (Correct Answer)
GERD and esophageal disorders Explanation: ***Smoking***
- **Smoking** is the most significant risk factor for **squamous cell carcinoma** of the esophagus, which is strongly suggested by the biopsy findings of **dysplastic cells without glands or mucin**.
- The combination of **progressive dysphagia** (solids to liquids) and smoking history in an **African American male** fits the classic demographic and presentation pattern for esophageal squamous cell carcinoma.
*Gastroesophageal reflux disease*
- **GERD** primarily leads to **esophageal adenocarcinoma** through **Barrett's esophagus**, which would show **glandular metaplasia** and **increased mucin production** on biopsy.
- The biopsy explicitly states **absence of glands and mucin**, making GERD-related adenocarcinoma unlikely as the primary pathologic process.
*Obesity*
- **Obesity** increases risk of **esophageal adenocarcinoma** by worsening **GERD** and promoting **Barrett's esophagus** development.
- Since the biopsy findings suggest **squamous cell carcinoma** rather than adenocarcinoma, obesity is not the most direct contributing factor in this case.
*Drinking extremely hot beverages*
- **Hot beverage consumption** is indeed a risk factor for **squamous cell carcinoma** of the esophagus, particularly in certain geographic regions.
- However, **smoking** remains the more prevalent and significant risk factor globally, especially when combined with **alcohol use**, making it the primary contributor.
*Radiation exposure in the past 6 months*
- **Radiation exposure** can increase risk of esophageal cancer, including **squamous cell carcinoma**, but typically requires a **longer latency period** (years to decades).
- A **6-month timeframe** is insufficient for radiation-induced carcinogenesis to manifest as advanced cancer with dysphagia and dysplastic changes.
GERD and esophageal disorders US Medical PG Question 8: A 28-year-old male presents to his primary care physician with complaints of intermittent abdominal pain and alternating bouts of constipation and diarrhea. His medical chart is not significant for any past medical problems or prior surgeries. He is not prescribed any current medications. Which of the following questions would be the most useful next question in eliciting further history from this patient?
- A. "Does the diarrhea typically precede the constipation, or vice-versa?"
- B. "Is the diarrhea foul-smelling?"
- C. "Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life"
- D. "Are the symptoms worse in the morning or at night?"
- E. "Can you tell me more about the symptoms you have been experiencing?" (Correct Answer)
GERD and esophageal disorders Explanation: ***Can you tell me more about the symptoms you have been experiencing?***
- This **open-ended question** encourages the patient to provide a **comprehensive narrative** of their symptoms, including details about onset, frequency, duration, alleviating/aggravating factors, and associated symptoms, which is crucial for diagnosis.
- In a patient presenting with vague, intermittent symptoms like alternating constipation and diarrhea, allowing them to elaborate freely can reveal important clues that might not be captured by more targeted questions.
*Does the diarrhea typically precede the constipation, or vice-versa?*
- While knowing the sequence of symptoms can be helpful in understanding the **pattern of bowel dysfunction**, it is a very specific question that might overlook other important aspects of the patient's experience.
- It prematurely narrows the focus without first obtaining a broad understanding of the patient's overall symptomatic picture.
*Is the diarrhea foul-smelling?*
- Foul-smelling diarrhea can indicate **malabsorption** or **bacterial overgrowth**, which are important to consider in some gastrointestinal conditions.
- However, this is a **specific symptom inquiry** that should follow a more general exploration of the patient's symptoms, as it may not be relevant if other crucial details are missed.
*Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life*
- Quantifying pain intensity is useful for assessing the **severity of discomfort** and monitoring changes over time.
- However, for a patient with intermittent rather than acute, severe pain, understanding the **character, location, and triggers** of the pain is often more diagnostically valuable than just a numerical rating initially.
*Are the symptoms worse in the morning or at night?*
- Diurnal variation can be relevant in certain conditions, such as inflammatory bowel diseases where nocturnal symptoms might be more concerning, or functional disorders whose symptoms might be stress-related.
- This is another **specific question** that should come after gathering a more complete initial picture of the patient's symptoms to ensure no key information is overlooked.
GERD and esophageal disorders US Medical PG Question 9: A 37-year-old man presents to his primary care provider with dysphagia. He notes that his symptoms began several weeks ago and have worsened over time. He now has trouble swallowing solids and liquids. He denies any other symptoms. He has no significant past medical history. Travel history reveals a recent trip to South America but no other travel outside the United States. His temperature is 100°F (37.8°C), blood pressure is 120/81 mmHg, pulse is 99/min, respirations are 14/min, and oxygen saturation is 98% on room air. HEENT exam is unremarkable. He has no palpable masses in his abdomen. What is the most appropriate next step in management?
- A. Nifurtimox
- B. Barium swallow (Correct Answer)
- C. Myotomy
- D. Manometry
- E. Endoscopy
GERD and esophageal disorders Explanation: ***Barium swallow***
- For a patient with **progressive dysphagia to both solids and liquids**, a **motility disorder** (particularly **achalasia**) is most likely, especially given the travel history to **South America** (Chagas disease risk).
- **Barium swallow (esophagram)** is the **preferred initial diagnostic test** for suspected esophageal motility disorders as it is **non-invasive**, provides excellent visualization of esophageal anatomy, and can demonstrate characteristic findings such as **"bird's beak" appearance** in achalasia or dilated esophagus with poor peristalsis.
- This test helps distinguish between **mechanical obstruction** and **motility disorders** without the risks associated with endoscopy.
*Endoscopy*
- While endoscopy allows direct visualization and biopsy capability, it is **not the first-line test** for suspected motility disorders.
- Endoscopy is more appropriate when dysphagia presents with **solids only** (suggesting mechanical obstruction or malignancy) or when barium swallow reveals concerning findings requiring tissue diagnosis.
- In a young patient (37 years) with dysphagia to liquids, malignancy is less likely, making the invasive nature of endoscopy less justified as the initial test.
*Manometry*
- **Esophageal manometry** is the **gold standard for confirming** esophageal motility disorders like achalasia.
- However, it is typically performed **after** structural abnormalities are ruled out with imaging (barium swallow), not as the initial diagnostic test.
- Manometry provides definitive diagnosis but doesn't evaluate for anatomical causes of dysphagia.
*Nifurtimox*
- This antiparasitic treats **Chagas disease** (*Trypanosoma cruzi*), which can cause esophageal dysmotility.
- Treatment should **never precede diagnosis**; the patient needs diagnostic workup first to confirm the etiology of dysphagia.
- Nifurtimox is only indicated after confirming active Chagas infection with serologic testing.
*Myotomy*
- **Heller myotomy** is a **definitive surgical treatment** for achalasia, not a diagnostic procedure.
- This intervention is only appropriate after diagnosis is established and medical/endoscopic therapies have been considered.
- Performing surgery without diagnostic confirmation would be inappropriate management.
GERD and esophageal disorders US Medical PG Question 10: 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?
- A. Endoscopy (Correct Answer)
- B. Omeprazole trial
- C. Manometry
- D. Barium swallow
- E. CT scan
GERD and esophageal disorders Explanation: ***Endoscopy***
- The patient presents with **dysphagia to solids and liquids**, significant for **recent weight loss**, and a **history of smoking**, all of which are **alarm symptoms** necessitating an upper endoscopy to rule out malignancy.
- While he has **GERD symptoms** as well (retrosternal burning), the presence of alarm features mandates a direct investigation of the upper GI tract rather than empirical treatment.
*Omeprazole trial*
- An empirical trial of **PPIs** like omeprazole is appropriate for classic GERD symptoms without alarm features.
- However, **dysphagia to solids and liquids with associated weight loss**, especially in a patient with a significant **smoking history**, are alarm symptoms that require direct visualization via endoscopy, not just symptom management.
*Manometry*
- **Esophageal manometry** is used to evaluate the motility of the esophagus and diagnose conditions like achalasia or esophageal spasm.
- While the patient has dysphagia, **alarm symptoms (weight loss, smoking history)** raise concern for mechanical obstruction or malignancy, which should be investigated before motility disorders.
*Barium swallow*
- A **barium swallow** can identify structural abnormalities like strictures, masses, or webs, and also assess motility.
- However, in the context of alarm symptoms, a **barium swallow is less sensitive** for detecting subtle mucosal changes or early malignancy compared to endoscopy, and any positive findings would still prompt an endoscopy.
*CT scan*
- A **CT scan of the chest and abdomen** is useful for assessing extraluminal pathology, mediastinal involvement, or distant metastases.
- While it may eventually be part of staging if a malignancy is found, the **initial investigation for esophageal symptoms and alarm features** focuses on direct luminal visualization with endoscopy to identify the primary pathology.
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