What is the next step in diagnosis for a patient with persistent gastroesophageal reflux disease (GERD) symptoms and dysphagia, unresponsive to cimetidine (histamine H2-receptor antagonist) and lansoprazole (proton pump inhibitor)?

Upper Endoscopy is the Next Diagnostic Step for Refractory GERD with Dysphagia

The next step in diagnosis for this patient with persistent GERD symptoms and dysphagia despite treatment with cimetidine and lansoprazole should be an upper gastrointestinal endoscopy.

Rationale for Upper Endoscopy

The patient presents with two key clinical features that warrant immediate endoscopic evaluation:

1. Refractory GERD symptoms: The patient has failed treatment with both an H2-receptor antagonist (cimetidine) and a proton pump inhibitor (lansoprazole), meeting the definition of refractory GERD 1.

2. Dysphagia: The symptom of "food getting caught in throat when eating quickly" indicates dysphagia, which is an alarm symptom that requires prompt investigation 1.

Diagnostic Algorithm for Refractory GERD

Step 1: Confirm Medication Compliance and Optimization

• Ensure PPI is being taken 30-60 minutes before meals
• Consider increasing to twice-daily PPI dosing if not already implemented 1, 2

Step 2: Endoscopic Evaluation

• Upper endoscopy is strongly recommended when:
  • GERD symptoms persist despite PPI therapy
  • Alarm symptoms (like dysphagia) are present
  • Symptoms have been present for extended periods 1

Step 3: Biopsy Protocol During Endoscopy

• Multiple biopsies from different levels of the esophagus
• Specific evaluation for:
  • Erosive esophagitis (graded by Los Angeles classification)
  • Barrett's esophagus (evaluated using Prague classification)
  • Eosinophilic esophagitis (particularly important in dysphagia)
  • Assessment of hiatal hernia 1

Why Endoscopy is Critical in This Case

The combination of refractory GERD and dysphagia raises significant concerns for several conditions that require direct visualization:

1. Eosinophilic Esophagitis (EoE): This condition frequently presents with dysphagia and food impaction, and can be resistant to PPI therapy. The British Society of Gastroenterology guidelines strongly recommend endoscopy and biopsy to exclude EoE in patients with typical GERD symptoms refractory to PPIs who have dysphagia 1.

2. Structural Abnormalities: Dysphagia suggests a possible mechanical obstruction that requires direct visualization, such as strictures, rings, or tumors 1.

3. Severe Erosive Disease: Endoscopy can identify the presence and severity of esophagitis that may be contributing to symptoms 1.

Alternative Diagnostic Tests to Consider After Endoscopy

If endoscopy results are non-diagnostic or additional information is needed:

1. Ambulatory pH Monitoring:

   • Preferably 96-hour wireless pH monitoring off medication
   • Helps confirm and phenotype GERD or rule it out 1

2. Combined pH-Impedance Monitoring:

   • Particularly useful if non-acid reflux is suspected
   • Can be performed while on PPI therapy to evaluate ongoing reflux 1

3. Esophageal Manometry:

   • Evaluates esophageal motility disorders
   • Important before considering surgical interventions 3

Common Pitfalls to Avoid

1. Continuing to escalate acid suppression without diagnostic testing: Simply increasing PPI dose without confirming the diagnosis can delay identification of the underlying cause 2.

2. Overlooking eosinophilic esophagitis: EoE is increasingly recognized as a cause of dysphagia and can be missed without appropriate biopsies 1.

3. Assuming symptoms are due to acid reflux: Non-acid reflux or motility disorders may be responsible for symptoms despite acid suppression 1.

4. Delaying endoscopy in patients with dysphagia: Dysphagia is an alarm symptom that warrants prompt evaluation to rule out serious conditions 1.

Upper endoscopy represents the most appropriate next step for this patient with the dual concerns of refractory GERD and dysphagia, as it provides direct visualization of the esophagus and allows for targeted biopsies to establish a definitive diagnosis that will guide further management.