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 for solid foods, the most appropriate initial study would be an oesophago-gastro-duodenoscopy (OGD) with oesophageal biopsies. This procedure allows direct visualization of the oesophagus and enables histological sampling to rule out and treat mucosal and structural disorders, as recommended by the British Society of Gastroenterology guidelines 1. The combination of age, smoking history, and dysphagia raises concern for oesophageal pathology, particularly malignancy, and OGD is the preferred investigation in patients with oesophageal dysphagia.

Key Considerations

• OGD allows for direct visual inspection of the oesophagus and histological sampling, making it the preferred investigation in patients with oesophageal dysphagia 1.
• A barium swallow should be considered where endoscopy is not possible and/or where structural disorders require further scrutiny, but it lacks the ability to obtain tissue samples and may miss subtle mucosal abnormalities 1.
• The patient's symptoms and risk factors, including smoking history and dysphagia for solids, warrant prompt evaluation with OGD to exclude eosinophilic oesophagitis and other oesophageal pathologies 1.

Clinical Recommendations

• The patient should undergo OGD and biopsy at two levels in the oesophagus to exclude eosinophilic oesophagitis and other oesophageal pathologies 1.
• The patient should be instructed to continue a modified diet that avoids foods causing symptoms until the procedure is completed.
• The patient should be counseled on smoking cessation regardless of the endoscopy findings, as smoking is a significant risk factor for oesophageal cancer.

From the Research

Diagnostic Approach for Dysphagia

The diagnostic approach for a 48-year-old smoker with dysphagia (difficulty swallowing) for solid foods involves several steps:

• Initial evaluation to determine the location and cause of dysphagia, which can be classified as oropharyngeal or esophageal 2
• Imaging studies, such as fluoroscopic studies (e.g., modified barium swallow and esophagography), to evaluate the esophagus for structural abnormalities and assess function 2
• Endoscopic evaluation, such as esophagogastroduodenoscopy (EGD), to visualize the esophagus and identify any mucosal abnormalities or strictures 3, 4

Specific Considerations for Solid Food Dysphagia

For patients with progressive or solid food dysphagia, evaluation for esophageal strictures is necessary:

• Barium esophagram and endoscopy can define strictures as benign or malignant 4
• Esophageal dilation with acid-suppressing medications may be used to manage benign strictures 4
• For esophageal dysphagia, management depends on the etiology and may include endoscopic dilation, myotomy, or topical steroid therapy 3

Differential Diagnosis

The differential diagnosis for dysphagia includes:

• Benign or malignant structural lesions
• Esophageal motility abnormalities
• Oropharyngeal dysfunction (including aspiration)
• Neuromuscular disorders
• Postsurgical changes
• Gastroesophageal reflux disease 2
• Eosinophilic esophagitis, which can be triggered by hypersensitivity reactions and may present with recurrent dysphagia 5

Treatment Options

Treatment options for dysphagia depend on the underlying cause:

• Esophageal dilation and acid-suppressing medications for benign strictures 4
• Topical steroid therapy for eosinophilic esophagitis 5
• Palliative measures, such as esophageal stenting or laser therapy, for malignant dysphagia 6