For a patient with dysphagia and narrowing, should I refer to GI (Gastroenterology) or ENT (Ear, Nose, and Throat) first?

From the Guidelines

For a patient with dysphagia and narrowing, you should refer to Gastroenterology (GI) first, especially if the symptoms suggest lower esophageal issues. The location of symptoms can guide your decision - if the patient reports food getting stuck in the chest area or has symptoms of acid reflux, GI is appropriate. GI specialists are equipped to perform endoscopy to visualize the esophagus, identify strictures, and potentially dilate narrowed areas during the same procedure, as recommended by the UK guidelines on oesophageal dilatation in clinical practice 1. They can also evaluate for conditions like eosinophilic esophagitis, GERD, or esophageal cancer. However, if the patient describes difficulty initiating swallowing or has symptoms localized to the throat, voice changes, or recurrent aspiration, an ENT referral would be more appropriate as these suggest oropharyngeal dysphagia. In cases of diagnostic uncertainty, starting with a modified barium swallow study can help determine which specialist would be most appropriate, as suggested by the British Society of Gastroenterology guidelines for oesophageal manometry and oesophageal reflux monitoring 1. Some complex cases may ultimately require evaluation by both specialties, but beginning with GI is generally the most efficient approach for dysphagia with narrowing, considering the high prevalence of esophageal abnormalities identifiable by endoscopy in patients with eosinophilic esophagitis 1.

Key considerations in making this decision include:

• The location and nature of the patient's symptoms
• The potential for underlying conditions such as eosinophilic esophagitis, GERD, or esophageal cancer
• The availability and utility of diagnostic tools like endoscopy and modified barium swallow studies
• The importance of a multidisciplinary approach in complex cases, involving both GI and ENT specialists.

From the Research

Dysphagia with Narrowing: GI or ENT Referral

• The decision to refer a patient with dysphagia and narrowing to either GI (Gastroenterology) or ENT (Ear, Nose, and Throat) depends on the underlying cause of the condition.
• Studies have shown that dysphagia can be associated with various underlying disorders, including malignant oesophageal stricture, reflux esophagitis, and eosinophilic esophagitis 2, 3, 4, 5.
• ENT specialists play a crucial role in the diagnosis and management of dysphagia, particularly in cases where the condition is related to swallowing disorders 6.
• However, GI specialists are more likely to be involved in the diagnosis and treatment of oesophageal disorders, such as strictures and narrowing 2, 3, 4, 5.
• In cases where the underlying cause of dysphagia is unclear, a referral to GI may be more appropriate, as they can perform endoscopic examinations and other diagnostic tests to determine the cause of the condition 2, 3, 4, 5.
• Ultimately, the decision to refer to GI or ENT should be based on the individual patient's symptoms and medical history, as well as the availability of specialist services in the area.

Key Findings

• Malignant oesophageal stricture is a common cause of dysphagia, particularly in older adults 2.
• Eosinophilic esophagitis is a chronic condition that can cause solid food dysphagia and narrowing of the oesophagus 3, 4, 5.
• Endoscopic dilation is a safe and effective treatment for dysphagia caused by oesophageal strictures and narrowing 3, 4, 5.
• ENT specialists can play a key role in the diagnosis and management of swallowing disorders, including dysphagia 6.