What is the appropriate workup for a patient presenting with dysphagia (difficulty swallowing)?

From the Guidelines

The most appropriate initial workup for a patient presenting with dysphagia is an upper endoscopy (EGD) with oesophageal biopsies to rule out and treat mucosal and structural disorders, as recommended by the British Society of Gastroenterology guidelines 1. This approach allows for direct visualization of the esophagus and histological sampling, which is essential for identifying the underlying cause of dysphagia. The guidelines suggest that patients with dysphagia should undergo OGD and biopsy at two levels in the oesophagus to exclude eosinophilic oesophagitis in the absence of a mucosal or structural cause for their symptoms 1. In cases where endoscopy is not possible, a barium swallow study may be considered as an alternative diagnostic tool 1. It is also important to note that contrast radiology can be a useful adjunct to endoscopic examination in the diagnosis of a patient with dysphagia, particularly in countries with limited healthcare resources or in situations where a patient is unable or unwilling to undergo endoscopic examination 1. Some studies suggest that early dysphagia screening is recommended for acute stroke patients to identify dysphagia or aspiration, which can lead to pneumonia, malnutrition, dehydration, and other complications 1. However, the most recent and highest quality study prioritizes upper endoscopy (EGD) as the initial diagnostic test for patients presenting with dysphagia 1.

Key considerations in the workup of dysphagia include:

• Thorough history and physical examination to distinguish between oropharyngeal and esophageal dysphagia
• Diagnostic testing with upper endoscopy (EGD) and oesophageal biopsies
• Barium swallow study or modified barium swallow as alternative diagnostic tools
• Additional tests such as esophageal manometry, 24-hour pH monitoring, and chest imaging (CT or MRI) as needed
• Laboratory tests including complete blood count, basic metabolic panel, and thyroid function tests.

By prioritizing upper endoscopy (EGD) as the initial diagnostic test, clinicians can effectively identify the underlying cause of dysphagia and provide targeted treatment to improve patient outcomes.

From the Research

Dysphagia Workup

The workup for a patient presenting with dysphagia (difficulty swallowing) typically involves a combination of diagnostic tests to determine the underlying cause.

• The initial evaluation may include a patient history, physical and neurologic examination, and careful videofluoroscopic study of pharyngeal dynamics for suspected oropharyngeal dysphagia 2.
• For suspected esophageal dysphagia, the initial evaluation may include a patient history and barium swallow with esophagography 2.
• Esophagogastroduodenoscopy (EGD) is often the first step in the evaluation of dysphagia, with further testing pursued if the results are negative 3.
• If no mucosal, structural, or motor esophageal disorders are identified with persisting symptoms, functional dysphagia is considered 3.
• Other diagnostic tests that may be used in the workup of dysphagia include:
  • Modified barium swallow procedure, which enables appropriate diagnosis and treatment 4.
  • Videoendoscopic evaluation of dysphagia (VEED), which provides a more detailed understanding of the component anatomic and functional deficits that comprise a given patient's swallowing problem 5.
  • Barium esophagram, which can help identify abnormalities in the esophagus 3.
  • Esophageal high resolution manometry, which can help diagnose motility disorders of the esophagus 3.

Diagnostic Yield

The diagnostic yield of endoscopy and subsequent tests in the evaluation of dysphagia is significant, with endoscopy providing a diagnosis in over 75% of patients presenting with dysphagia 3.

• Secondary tests, such as barium esophagram and esophageal high resolution manometry, are useful when endoscopy does not provide a diagnosis 3.
• Benign strictures and GERD-related etiologies are leading causes of dysphagia, and proton pump inhibitor (PPI) therapy is useful even when testing is negative 3.
• Functional dysphagia is extremely rare, accounting for less than 2.5% of all dysphagia cases 3.

Patient Risk

Patients with dysphagia are at risk of aspirating food or saliva into the lungs, creating a potentially life-threatening medical condition 6.

• The swallowing mechanism is complex, involving more than 50 pairs of muscles, and impairment of any one or more of these muscles may result in a serious health risk to the patient 6.