How should a 72-year-old patient with intermittent globus sensation, throat discomfort, mild shortness of breath, occasional reflux, and jaw radiation be evaluated and managed to rule out esophageal and cardiac causes?

Immediate Cardiac Evaluation is Essential Before Pursuing Esophageal Workup

This 72-year-old patient requires urgent cardiac evaluation with ECG and troponin testing before any esophageal investigation, given the combination of jaw radiation, mild dyspnea, and prolonged episodes of discomfort—features that cannot be safely dismissed as benign reflux or globus. 1

Critical Red Flags Demanding Cardiac Assessment

The presentation contains concerning features that overlap with acute coronary syndrome:

• Jaw radiation with throat/chest discomfort
• Mild shortness of breath
• Prolonged episodes (hours duration, persisting until lunchtime)
• Age 72 years (high-risk demographic)

While the patient denies classic anginal features (arm radiation, diaphoresis, palpitations), the 2021 AHA/ACC Chest Pain Guidelines emphasize that esophageal and cardiac pain are notoriously difficult to distinguish clinically 1. Gastroesophageal symptoms can mimic myocardial ischemia with squeezing sensations lasting minutes to hours, often worse at night 1. The absence of typical anginal symptoms does not exclude cardiac disease.

Algorithmic Approach to Evaluation

Step 1: Rule Out Cardiac Etiology (Immediate)

• ECG and cardiac biomarkers (troponin) now
• Blood pressure assessment (already initiated per note)
• If any abnormalities or high clinical suspicion → cardiology consultation and stress testing or coronary imaging 1

Step 2: Assess for Alarm Symptoms Requiring Urgent Endoscopy

Once cardiac causes excluded, evaluate for:

• Dysphagia with food obstruction (patient denies—liquids/solids pass normally)
• Odynophagia (painful swallowing—not reported)
• Weight loss (not mentioned)
• GI bleeding or anemia (not reported)
• Recurrent vomiting (not present)

These alarm symptoms mandate upper endoscopy within 2 weeks 1, 2. This patient's "sensation of something stuck" without true dysphagia (food passes normally) suggests globus rather than mechanical obstruction, but the prolonged nature and jaw radiation elevate concern.

Step 3: Diagnostic Testing Strategy

Given this patient's profile—isolated globus with occasional reflux but no typical GERD symptoms and no alarm features—the evidence supports:

Option A: Direct diagnostic testing (preferred approach)

• Upper endoscopy to exclude structural pathology (strictures, rings, malignancy, esophagitis) 2, 3
• Consider biphasic esophagram if endoscopy unavailable, as it has 96% sensitivity for esophageal/GE junction cancer and superior detection of rings/strictures compared to endoscopy 4

The 2023 AGA guidelines specifically recommend diagnostic testing before empiric PPI therapy in patients with extraesophageal manifestations (like globus) who lack typical GERD symptoms 5. An empiric PPI trial has poor diagnostic performance for extraesophageal reflux (sensitivity 71-78%, specificity only 41-54% even for typical reflux symptoms) 5.

Option B: Empiric PPI trial (less preferred here)

• Only reasonable if patient had typical heartburn/regurgitation as predominant symptoms 2
• This patient reports reflux is "different from usual" and globus is the primary complaint
• If pursued: pantoprazole 40mg once daily 30-60 minutes before breakfast, escalate to twice daily if no response after 4 weeks 2
• Failure of 4-8 weeks of twice-daily PPI mandates endoscopy 2, 3

Step 4: Additional Testing if Initial Workup Negative

If endoscopy normal and symptoms persist despite PPI trial:

• Esophageal manometry to evaluate motility disorders (achalasia, esophageal spasm) that can cause globus and retrosternal discomfort 1, 3
• Ambulatory pH-impedance monitoring (off PPI for 7 days) to document reflux-symptom correlation 3
• Nasolaryngoscopy to assess for laryngopharyngeal findings 6

Management Based on Findings

If reflux disease confirmed:

• PPI therapy (any agent: omeprazole, pantoprazole, esomeprazole) once daily, advance to twice daily if needed 2, 7
• Long-term PPI reduces stricture recurrence and Schatzki's ring relapse 7

If structural abnormality found:

• Esophageal stricture → dilation with continued PPI 7
• Schatzki's ring → dilation to 16-20mm with long-term PPI 7
• Malignancy → oncology referral

If all testing negative (functional globus):

• Lifestyle modifications
• Consider cognitive-behavioral therapy referral 1
• Reassurance regarding benign prognosis

Critical Pitfalls to Avoid

1. Do not attribute jaw radiation to reflux without excluding cardiac disease first—this is the most dangerous error in this case
2. Do not rely on "atypical" presentation to exclude ACS in a 72-year-old with dyspnea
3. Do not perform prolonged empiric PPI trials in patients with extraesophageal symptoms lacking typical GERD—proceed to objective testing 5
4. Do not miss alarm symptoms—true dysphagia (even intermittent) requires endoscopy 2
5. Do not assume normal barium study excludes all pathology—endoscopy is more sensitive for mucosal disease and allows biopsy 4

The jaw radiation and dyspnea in this elderly patient mandate cardiac evaluation before pursuing any gastrointestinal workup, regardless of how "esophageal" the globus sensation appears.