For a patient with dysphagia and significant weight loss, what is the most appropriate initial diagnostic intervention?

• A. Endoscopy with biopsy
• B. Chest X-ray
• C. Barium esophagogram
• D. CT scan of the thorax

Answer: (A)

Dysphagia with significant weight loss raises concern for a possible obstructing lesion in the esophagus, including cancer. The best initial test is upper endoscopy with biopsy because it allows direct visualization of the esophageal mucosa, enables targeted biopsies of any suspicious lesion, and provides a definitive histopathologic diagnosis to guide management.

Other tests have value in certain contexts but aren’t as helpful for establishing a diagnosis here: a chest X-ray often misses intraluminal pathology; a barium esophagram can reveal strictures or swallowing problems but cannot confirm cancer and does not yield tissue for diagnosis; a CT scan of the chest assesses extent after diagnosis but does not replace the need for tissue confirmation at the outset.