What is the appropriate study for a 48-year-old smoker with dysphagia (difficulty swallowing) for solid foods?

From the Guidelines

For a 48-year-old smoker with dysphagia (difficulty swallowing) for solid foods, the most appropriate initial study would be an upper endoscopy (EGD) to directly visualize the esophageal mucosa and permit tissue sampling if needed, as recommended by the British Society of Gastroenterology guidelines 1. This approach is particularly important given the patient's age and smoking history, which increase the risk for esophageal cancer. The combination of endoscopy can identify common causes of dysphagia including esophageal strictures, rings, webs, motility disorders, and malignancies. Some key points to consider in the diagnostic workup of dysphagia include:

• Assessing the extent of disease, the functional degree of swallowing impairment, and confirming the cause of dysphagia, as outlined in the Journal of the National Comprehensive Cancer Network 1
• Considering a barium swallow as a useful adjunct to endoscopic examination in the diagnosis of a patient with dysphagia, particularly in situations where endoscopy is not possible or where structural disorders require further scrutiny 1
• The patient should be advised to continue a modified diet (soft or pureed foods) until diagnosis and treatment are established, and smoking cessation should be strongly encouraged as smoking is a risk factor for many esophageal disorders and can worsen symptoms. If the initial endoscopy is inconclusive and motility disorders are suspected, esophageal manometry may be indicated as a follow-up test. It's worth noting that a more recent study from the Journal of the American College of Radiology 1 suggests that a modified barium swallow examination may be of benefit in identifying the cause of dysphagia, particularly if structural abnormalities have been excluded by direct endoscopic visualization. However, the British Society of Gastroenterology guidelines 1 provide a stronger recommendation for the use of endoscopy as the initial diagnostic test.

From the Research

Diagnostic Approach for Dysphagia

• The appropriate study for a 48-year-old smoker with dysphagia (difficulty swallowing) for solid foods should include radiologic and endoscopic evaluation, as suggested by 2.
• A barium esophagogram can be useful in demonstrating structural defects, while endoscopy with biopsies can help exclude malignancy and diagnose conditions such as esophagitis or obstruction, as mentioned in 3 and 4.
• A video esophagram can also provide a comprehensive assessment of morphologic abnormalities, oropharyngeal swallowing function, esophageal motility, and gastroesophageal reflux, as noted in 5.

Consideration of Gastroesophageal Reflux Disease (GERD)

• GERD is a common condition that can cause dysphagia, and its diagnosis can often be determined by typical symptoms such as heartburn and regurgitation, as stated in 6.
• However, in patients with atypical symptoms like dysphagia, further evaluation with endoscopy, esophageal manometry, and esophageal pH monitoring may be necessary, as recommended in 6.
• The patient's history of smoking and potential for GERD should be considered, as smoking is a risk factor for developing GERD, as mentioned in 6.

Evaluation and Management

• The evaluation of dysphagia should include a careful history and physical examination, followed by diagnostic tests such as barium esophagogram, endoscopy, and biopsies, as suggested by 2 and 4.
• The management of GERD and dysphagia may involve lifestyle changes, medication with proton pump inhibitors, and surgery, as discussed in 6.
• The patient's treatment plan should be individualized based on the underlying cause of dysphagia and the presence of any comorbid conditions, as implied by 3 and 6.