What is the most appropriate next test for a 62-year-old man with regurgitation, coughing, and rare dysphagia, with well-controlled heartburn on over-the-counter Proton Pump Inhibitors (PPIs)?

From the Guidelines

The most appropriate next test for this 62-year-old man with regurgitation, coughing, and rare dysphagia despite well-controlled heartburn on over-the-counter PPIs is an upper endoscopy (esophagogastroduodenoscopy or EGD). This procedure allows direct visualization of the esophagus, stomach, and duodenum to evaluate for structural abnormalities such as esophagitis, Barrett's esophagus, strictures, or malignancy. The patient's age (over 60) and presence of dysphagia are concerning "alarm features" that warrant endoscopic evaluation, even if his heartburn symptoms are controlled with medication, as suggested by the American Gastroenterological Association medical position statement on the management of gastroesophageal reflux disease 1.

Key Considerations

• The patient's symptoms of regurgitation, coughing, and rare dysphagia, despite well-controlled heartburn on PPIs, suggest the need for further evaluation to rule out alternative diagnoses or complications of reflux disease.
• The British Society of Gastroenterology guidelines for oesophageal manometry and oesophageal reflux monitoring recommend that patients with dysphagia should preferably have an endoscopy with oesophageal biopsies to rule out and treat mucosal and structural disorders prior to manometry 1.
• Endoscopy is a crucial step in the diagnostic algorithm for patients with symptoms suggestive of GERD, especially when "alarm features" such as dysphagia are present, as it allows for the direct visualization of the esophagus and the collection of biopsy specimens to evaluate for conditions like eosinophilic esophagitis.

Procedure and Follow-Up

The endoscopy can be performed as an outpatient procedure under conscious sedation and typically takes 15-30 minutes. The patient should fast for at least 6-8 hours before the procedure. If the endoscopy is normal, additional testing such as esophageal manometry or 24-hour pH monitoring might be considered to evaluate for motility disorders or confirm the diagnosis of GERD. However, given the current evidence and guidelines, upper endoscopy is the most appropriate next step in the management of this patient, prioritizing the evaluation of structural abnormalities and the collection of biopsy specimens over other diagnostic tests.

From the Research

Diagnostic Approach

To determine the most appropriate next test for the 62-year-old man with regurgitation, coughing, and rare dysphagia, with well-controlled heartburn on over-the-counter Proton Pump Inhibitors (PPIs), we need to consider the symptoms and the information provided by the barium esophagram, although the image itself is not available.

Consideration of Symptoms

The patient's symptoms of regurgitation, coughing, and rare dysphagia, along with the absence of significant weight loss and well-controlled heartburn, suggest an esophageal motility disorder. Achalasia is a primary motility disorder characterized by impaired lower esophageal sphincter (LES) relaxation and absence of esophageal peristalsis, leading to symptoms similar to those presented by the patient.

Diagnostic Tests

The following diagnostic tests are considered:

• High-resolution manometry (HRM): This is the gold standard for diagnosing achalasia and other esophageal motility disorders 2, 3. HRM can assess the function of the esophagus and LES, providing detailed information about esophageal motility and pressure.
• Upper endoscopy: While useful for evaluating the esophageal mucosa and ruling out other conditions like esophagitis or cancer, it does not directly assess motility.
• 48-hour Bravo pH testing: This test is more commonly used to assess acid reflux rather than motility disorders.
• Endolumenal functional lumen imaging probe (EndoFLIP): This is a newer technology that can assess esophageal function and distensibility but is not as widely used or established as HRM for diagnosing achalasia.

Most Appropriate Next Test

Given the patient's symptoms suggestive of an esophageal motility disorder, such as achalasia, and the need for a detailed assessment of esophageal function, High-resolution manometry (HRM) is the most appropriate next test. HRM can provide a definitive diagnosis of achalasia or other motility disorders, guiding further treatment decisions 4, 2, 5, 3.

Key Points

• The patient's symptoms are consistent with an esophageal motility disorder.
• HRM is the gold standard for diagnosing achalasia and other esophageal motility disorders.
• HRM can guide treatment decisions based on the specific diagnosis and subtype of achalasia, if present.