What is the best next step for a 55-year-old male with a 10-year history of Gastroesophageal Reflux Disease (GERD) controlled on Proton Pump Inhibitors (PPI), presenting with dysphagia to solid food, significant weight loss, and a low Body Mass Index (BMI) of 15.4?

Best Next Step for 55-Year-Old Male with GERD and New Dysphagia

Endoscopy is the best next step for this 55-year-old male with long-standing GERD who presents with new dysphagia to solid food, significant weight loss, and low BMI. 1, 2

Rationale for Endoscopy

The American College of Physicians guidelines clearly state that upper endoscopy is indicated in patients with GERD who present with alarm symptoms, with dysphagia being specifically highlighted as one of these alarm symptoms 1. This patient presents with multiple concerning features:

1. Dysphagia to solid food - A critical alarm symptom requiring immediate evaluation
2. Significant weight loss - BMI of 15.4 indicates severe malnutrition
3. Age >50 years - Increases risk of malignancy
4. Long-standing GERD - 10-year history increases risk of complications

Diagnostic Yield of Endoscopy in This Scenario

Endoscopy has high diagnostic yield in patients with dysphagia. In a recent analysis of approximately 30,000 patients with dysphagia who underwent endoscopy, more than 50% had important clinical findings, with esophageal stricture being the most common 1. Given this patient's long history of GERD, the dysphagia could represent:

• Esophageal stricture
• Esophageal cancer
• Barrett's esophagus with dysplasia
• Severe erosive esophagitis

Why Other Options Are Less Appropriate

Barium Swallow (Option B)

While barium swallow can be useful in evaluating dysphagia, it is not the first-line test when a structural lesion such as malignancy is suspected in a high-risk patient. The American College of Radiology notes that in cases of unexplained dysphagia, a combined examination may be needed, but endoscopy offers the advantage of direct visualization and biopsy capability 1.

Manometry (Option C)

Esophageal manometry is primarily indicated after normal endoscopy findings in patients who haven't responded to PPI therapy 2. It should not be the first test in a patient with alarm symptoms and weight loss, as it cannot detect mucosal abnormalities or malignancy.

CT Abdomen (Option D)

CT is usually not indicated as initial imaging for dysphagia evaluation 1. While it may eventually be needed to stage a malignancy if found, endoscopy provides direct visualization and tissue diagnosis.

Clinical Approach Algorithm

1. First step: Upper endoscopy

   • Allows direct visualization of the esophageal mucosa
   • Enables biopsy of any suspicious lesions
   • Can identify strictures requiring dilation
   • Can diagnose Barrett's esophagus or malignancy

2. Subsequent steps based on endoscopy findings:

   • If stricture found: Dilation may be performed
   • If malignancy suspected: Biopsy and staging
   • If Barrett's esophagus: Appropriate surveillance protocol
   • If normal: Consider manometry to evaluate motility disorders

Common Pitfalls to Avoid

• Delaying endoscopy in patients with alarm symptoms like dysphagia and weight loss
• Attributing new symptoms solely to known GERD without appropriate investigation
• Starting empiric therapy without diagnostic evaluation in patients with alarm symptoms
• Overlooking the significance of weight loss (BMI 15.4 indicates severe malnutrition)

In summary, this patient's presentation with new-onset dysphagia, significant weight loss, and long-standing GERD clearly indicates the need for prompt upper endoscopy as the best next step in management.