What is the best initial step before proceeding to surgery for a 76-year-old man with chronic dysphagia, retrosternal chest pain, choking, postprandial cough, sensation of food sticking, and regurgitation?

Diagnostic Approach for Chronic Dysphagia with Progressive Symptoms

OGD with biopsy (Option D) is the best initial step before proceeding to surgery for a 76-year-old man with chronic dysphagia and associated symptoms of retrosternal chest pain, choking, postprandial cough, sensation of food sticking, and regurgitation. 1

Rationale for OGD with Biopsy as First-Line Investigation

1. Direct Visualization and Sampling:

   • OGD with biopsies provides direct visual inspection of the esophagus and allows for histological sampling
   • High diagnostic yield of 54% for identifying the cause of dysphagia 1
   • Essential to exclude malignancy, which is a significant concern in elderly patients with progressive dysphagia

2. Symptom Pattern Analysis:

   • The patient's symptoms (retrosternal chest pain, food sticking, regurgitation) strongly suggest esophageal dysphagia
   • These symptoms warrant direct visualization to rule out structural abnormalities before considering functional testing 1, 2

3. Age-Related Considerations:

   • At 76 years old with progressive symptoms, the risk of malignancy is significantly higher
   • OGD allows for immediate biopsy of suspicious lesions, which is critical before surgical planning 3

Comparison with Other Diagnostic Options

A. 24-hour Esophageal Acid Monitoring

• Only useful after structural causes have been excluded
• Limited utility as an initial test as it only evaluates for GERD and misses structural abnormalities
• Would not identify malignancy, strictures, or other mechanical obstructions 3

B. Rigid/Flexible Esophagoscopy

• While this allows visualization, it lacks the comprehensive approach of OGD with biopsy
• OGD is preferred as it allows examination of the stomach and duodenum as well 3

C. Esophageal Manometry

• Indicated only after structural abnormalities have been excluded
• Primarily useful for diagnosing motility disorders like achalasia
• Should be performed after imaging studies if motility disorder is suspected 1
• Not appropriate as first-line investigation in a patient with progressive symptoms 2

Diagnostic Algorithm for Chronic Dysphagia

1. Initial Assessment: OGD with biopsies at two levels in the esophagus

   • Allows direct visualization of mucosal abnormalities
   • Enables histological diagnosis of conditions like eosinophilic esophagitis
   • Can identify malignancy, strictures, webs, or other structural abnormalities 1

2. Secondary Testing (based on OGD findings):

   • If OGD shows structural abnormality → proceed to appropriate treatment
   • If OGD is normal or inconclusive → proceed to barium esophagram
   • If motility disorder is suspected after initial testing → perform esophageal manometry 2

3. Tertiary Testing:

   • Esophageal manometry if functional disorder is suspected
   • 24-hour pH monitoring if GERD is suspected as the cause 3

Important Clinical Considerations

• Malignancy Risk: Progressive dysphagia with weight loss in elderly patients should always raise concern for esophageal malignancy, making direct visualization crucial 3

• Surgical Planning: Before any surgical intervention, direct visualization and tissue diagnosis are essential to determine the appropriate surgical approach 3

• Common Pitfall: Proceeding directly to functional studies without ruling out structural abnormalities can lead to missed diagnoses of malignancy or other serious conditions 1

• Special Consideration: If perforation is suspected based on severe symptoms, a water-soluble contrast study should be performed before endoscopy 3

OGD with biopsy provides the most comprehensive initial assessment for this patient's presentation, allowing for both diagnosis and appropriate surgical planning while minimizing the risk of missing serious pathology.