What are the recommended next steps for a female patient with persistent sensation of sputum or food stuck in the throat after eating and drinking, unresponsive to clarithromycin and proton pump inhibitor therapy, despite prior gastroenterology and otolaryngology evaluations?

Endoscopy with Esophageal Biopsies is the Next Critical Step

Given the persistent sensation of food/sputum stuck in the throat despite PPI and clarithromycin (which appears to be a misunderstanding—clarithromycin is an antibiotic, not indicated for this symptom), and prior unrevealing GI/ENT evaluations, you should pursue upper endoscopy with systematic esophageal biopsies to evaluate for eosinophilic esophagitis (EoE) and other inflammatory esophageal disorders. 1, 2

Why Endoscopy Now?

This clinical presentation—globus sensation with food sticking, unresponsive to acid suppression—raises significant concern for eosinophilic esophagitis, which affects up to 70% of patients presenting with these symptoms 1. The 2022 BSG guidelines strongly recommend that patients with dysphagia (which includes the sensation of food sticking) and atopy should undergo endoscopy with biopsies, even if prior endoscopy appeared normal 1.

Critical Technical Details for Endoscopy:

• Obtain at least 6 biopsies from at least 2 different levels of the esophagus (proximal and distal) 1
• Biopsies must be taken while the patient is OFF PPIs for at least 3 weeks if EoE is suspected, as PPIs can mask eosinophilic inflammation 1
• Look for endoscopic features: rings, furrows, white exudates, strictures, or normal-appearing mucosa (30% of EoE cases have normal endoscopy) 1

The Clarithromycin Issue

Clarithromycin is an antibiotic with no role in treating globus or dysphagia symptoms 3. Its use here suggests either a misunderstanding or treatment of an unrelated condition. This medication should not influence your diagnostic approach to her throat symptoms.

Alternative Diagnoses to Consider During Endoscopy

The 2024 AGA guidelines highlight several inflammatory and immune-mediated esophageal disorders that present similarly 2:

• Lymphocytic esophagitis: Treat with swallowed topical corticosteroids or PPIs 2
• Esophageal lichen planus: Can occur without skin involvement and requires direct immunofluorescence 2
• Hypereosinophilic syndrome or EGPA: If absolute eosinophil count >1500 cells/μL 2
• Esophageal inlet patches: Multiple patches can cause chronic dysphagia and may require dilation 4

If Endoscopy is Normal

If endoscopy with adequate biopsies is truly normal, the next algorithmic steps are:

1. High-resolution manometry with impedance to evaluate for:

   • Motility disorders (can develop even after EoE remission) 2, 1
   • Upper esophageal sphincter dysfunction 5
   • Achalasia variants 2

2. 48-hour wireless pH-impedance monitoring OFF PPIs 6, 7:

   • Assess for non-acid reflux (which PPIs don't treat)
   • Evaluate symptom-reflux association using both Symptom Index and Symptom Association Probability 6
   • The 2019 BSG guidelines strongly recommend pH/impedance over pH alone for PPI-refractory symptoms 6

3. Videofluoroscopic swallowing study (VFSS) with multiple consistencies 8:

   • A 2025 study found abnormalities in 74% of patients with "food sticking" sensation despite normal endoscopy
   • Use solids during the study—they provide the highest diagnostic yield (50%) 8
   • Include esophageal phase evaluation, not just oropharyngeal

What NOT to Do

• Do not increase PPI dose beyond twice daily—the evidence shows no benefit 9, 7
• Do not perform anti-reflux surgery without objective confirmation of GERD 7—this is a critical pitfall
• Do not rely on allergy testing to guide dietary elimination if EoE is found 1
• Do not assume prior "normal" endoscopy ruled out EoE if inadequate biopsies were taken 1

Common Pitfall: The "Refractory GERD" Misdiagnosis

Many patients like yours are labeled as having "refractory GERD" when they actually have functional heartburn, hypersensitive esophagus, or EoE 7. The 2025 consensus on refractory reflux-like symptoms emphasizes that management must be personalized based on objective testing, not empiric escalation of acid suppression 7.

If EoE is Diagnosed

Treatment hierarchy per 2022 BSG guidelines 1:

1. Topical swallowed corticosteroids (budesonide or fluticasone) twice daily for 8-12 weeks
2. Six-food elimination diet with dietitian support (though compliance is challenging)
3. Repeat endoscopy with biopsies while on treatment to assess histological response—symptoms don't correlate with disease activity 1

The key insight: symptoms may persist despite histological remission, in which case motility evaluation becomes necessary 2, 1.