From the Guidelines
The next step in managing a 72-year-old man with dysphagia to both solids and liquids and significant unintentional weight loss should be an urgent endoscopic evaluation, specifically an esophagogastroduodenoscopy (EGD). This procedure will allow direct visualization of the upper gastrointestinal tract to identify the cause of his dysphagia, which could range from benign conditions like strictures or motility disorders to more concerning possibilities such as esophageal cancer 1. Given his age, the combination of progressive dysphagia affecting both solids and liquids, and significant weight loss, there is a high suspicion for malignancy that requires immediate investigation.
While awaiting the endoscopy, nutritional support should be initiated, which may include dietary modification with soft or pureed foods, nutritional supplements, or consultation with a dietitian. A swallowing evaluation by a speech-language pathologist may also be beneficial to assess his swallowing function and recommend appropriate dietary textures to reduce aspiration risk, as recommended by the ESPEN practical guideline 1. The urgency of this evaluation is justified by the need to rule out life-threatening conditions and prevent further nutritional deterioration, as dysphagia with weight loss in elderly patients is associated with increased morbidity and mortality.
Some key points to consider in the management of this patient include:
- The importance of endoscopy in diagnosing and treating mucosal and structural disorders, as highlighted by the British Society of Gastroenterology guidelines 1
- The potential need for oesophageal dilatation in the treatment of symptomatic narrowing of the oesophagus, as discussed in the UK guidelines on oesophageal dilatation 1
- The role of nutritional support and swallowing evaluation in managing dysphagia in elderly patients, as recommended by the ESPEN practical guideline 1.
From the Research
Diagnostic Evaluation
The next step in managing a 72-year-old man with dysphagia to both solids and liquids, and significant unintentional weight loss, would involve a thorough diagnostic evaluation to determine the underlying cause of his symptoms.
- Upper endoscopy is recommended to exclude malignancy and establish a diagnosis 2, 3, 4, 5.
- Barium swallow with fluoroscopy can help diagnose achalasia and other motility disorders 2, 3, 4, 5.
- High-resolution esophageal manometry is the gold standard for diagnosing achalasia and can provide information on the type of achalasia 3, 4, 5.
Potential Causes
The patient's symptoms of dysphagia to both solids and liquids, along with significant unintentional weight loss, could be caused by a number of disorders, including:
- Benign or malignant obstruction of the esophagus 2
- Inflammatory alterations of the mucosa 2
- Primary esophageal motility disorders, such as achalasia or diffuse esophageal spasm 2, 3, 4, 5
- Gastroesophageal reflux disease (GERD) 2, 5
- Eosinophilic esophagitis 2
Further Testing
Depending on the results of the initial diagnostic evaluation, further testing may be warranted, including: