Does a patient with odynophagia (painful swallowing) that resolves with Proton Pump Inhibitor (PPI) use require further workup?

From the Guidelines

Further workup is still indicated for odynophagia that improves with proton pump inhibitors (PPIs), as symptom improvement does not definitively rule out other potentially serious conditions. While symptom improvement with PPIs suggests acid-related pathology like gastroesophageal reflux disease (GERD) or erosive esophagitis, it is crucial to consider other conditions such as eosinophilic esophagitis, esophageal strictures, or even early malignancy 1. An upper endoscopy (EGD) is typically recommended to directly visualize the esophagus, obtain biopsies if needed, and exclude other pathologies, particularly in patients with alarm symptoms like weight loss, anemia, persistent symptoms despite therapy, or those over 45-50 years old with new-onset symptoms 1. Some key points to consider in the diagnostic process include:

• The use of PPI therapy for at least 8-12 weeks prior to assessment of histological response while on treatment, with a recommended dose of omeprazole 20 mg two times per day 1
• The potential need to withdraw PPIs for at least three weeks prior to endoscopy and biopsy to improve diagnostic accuracy and avoid the need for a repeat procedure 1
• The importance of documenting whether PPIs have been discontinued and for how long on the endoscopy report and histology request form when biopsies are taken to diagnose eosinophilic esophagitis 1 The timing of endoscopy may depend on symptom severity, duration, and risk factors, and while continuing the PPI during the diagnostic process is reasonable, relying solely on symptomatic improvement without proper evaluation could delay diagnosis of underlying conditions that require specific treatment beyond acid suppression 1.

From the FDA Drug Label

In adults, symptomatic response to therapy with lansoprazole does not preclude the presence of gastric malignancy. The answer is: Yes, further work up is still indicated, as symptomatic response to PPI therapy does not rule out the presence of gastric malignancy 2.

• Consider additional follow-up and diagnostic testing in adult patients who have a suboptimal response or an early symptomatic relapse after completing treatment with a PPI.
• In older patients, also consider an endoscopy.

From the Research

Odynophagia and PPI Use

• Odynophagia, or painful swallowing, can be a symptom of various esophageal disorders, including gastroesophageal reflux disease (GERD) and esophagitis 3.
• Proton pump inhibitors (PPIs) are commonly used to treat these conditions by reducing gastric acid secretion 4, 5.
• If odynophagia resolves with PPI use, it may indicate that the symptom is related to acid reflux or esophagitis.

Further Workup

• Despite resolution of symptoms with PPI use, further workup may still be indicated to rule out other underlying conditions, such as esophageal motility disorders or structural abnormalities 3, 6.
• Endoscopy and manometry are commonly used diagnostic tools to evaluate esophageal function and rule out other causes of dysphagia 3.
• A thorough assessment and management plan should be developed to address the underlying cause of odynophagia and prevent complications 6.

Considerations

• Treatment with PPIs can induce tolerance to histamine-2 receptor antagonists in some patients, which may affect the choice of treatment 7.
• A comprehensive approach to managing odynophagia should include consideration of the patient's overall health, medical history, and response to treatment 6.