What are the initial investigations for a patient presenting with sudden difficulty in swallowing?

Initial Investigations for Sudden Difficulty in Swallowing

For patients presenting with sudden difficulty in swallowing, initial investigations should include plain neck, chest, and abdominal radiographs, followed by CT scan if radiographs are negative or if complications are suspected, and endoscopy for persistent symptoms or suspected foreign body. 1

Diagnostic Algorithm for Sudden Dysphagia

Step 1: Initial Assessment and Basic Investigations

• Complete blood count (CBC)
• C-reactive protein (CRP)
• Blood gas analysis for base excess and lactate 1
• Plain radiography:
  • Neck, chest, and abdominal radiographs (biplanar)
  • Lateral projection is crucial to differentiate between tracheobronchial and esophageal foreign bodies
  • Note: Plain radiography has up to 47% false-negative rate; up to 85% for food bolus impaction, thin metal objects, wood, plastic, glass fragments, and fish/chicken bones 1

Step 2: Advanced Imaging (if indicated)

• CT scan should be performed when:
  • Plain radiographs are negative but symptoms persist
  • Perforation or other complications are suspected
  • Foreign body ingestion is suspected (especially bone fragments)
  • CT sensitivity is 90-100% and specificity 93.7-100% for foreign bodies 1, 2

Step 3: Endoscopic Evaluation

• Therapeutic flexible endoscopy is recommended as first-line treatment for:

  • Persistent esophageal foreign bodies
  • Persistent symptoms even with negative radiographic examination 1

• Timing of endoscopy:

  • Emergent (within 2-6 hours): Sharp-pointed objects, batteries, magnets, or complete esophageal obstruction
  • Urgent (within 24 hours): Other esophageal foreign bodies without complete obstruction 1

Special Considerations

Foreign Body Management

• For food bolus impaction, gentle pushing into the stomach is recommended first
• If unsuccessful, retrieval techniques using baskets, snares, and grasping forceps should be considered 1

Contrast Studies

• Contrast swallow is not recommended and should not delay other investigations/interventions
• Barium studies may coat foreign bodies and impair endoscopic visualization
• Water-soluble contrast should be used if perforation is suspected 1, 3

Type of Dysphagia Considerations

• Oropharyngeal dysphagia (difficulty initiating swallowing, coughing, choking):

  • Modified Barium Swallow (videofluoroscopy) is the first-line imaging 2
  • Evaluates oral cavity, pharynx, and cervical esophagus

• Esophageal dysphagia (sensation of food getting stuck after swallowing):

  • Esophagogastroduodenoscopy (OGD) with biopsies is recommended as initial diagnostic step 2
  • Barium esophagram as an adjunct 4

Pitfalls to Avoid

1. Relying solely on plain radiography can miss many foreign bodies due to high false-negative rates
2. Delaying endoscopy in cases of sharp objects, batteries, or complete obstruction can lead to serious complications including perforation
3. Using barium contrast in suspected perforation cases (use water-soluble contrast instead)
4. Failing to consider that distal esophageal lesions can cause symptoms perceived in the throat or neck 4
5. Not evaluating the entire esophagus in patients with pharyngeal symptoms, as abnormalities of the distal esophagus can cause referred dysphagia 1

By following this structured approach, clinicians can efficiently diagnose and manage patients presenting with sudden difficulty in swallowing, minimizing complications and improving outcomes.