What is the next step in managing a patient with dysphagia and a sensation of something being stuck in the esophagus, without halitosis, vomiting, or fever, and with mild anemia (Hb 11.6 g/dL)?

Management of Dysphagia with Sensation of Food Stuck in Esophagus

For a patient presenting with dysphagia, sensation of something stuck in the esophagus, and mild anemia (Hb 11.6 g/dL) without halitosis, vomiting, or fever, the recommended next step is to perform a biphasic esophagram (barium meal study) as the initial diagnostic test.

Rationale for Biphasic Esophagram as First-Line Investigation

• The American College of Radiology (ACR) Appropriateness Criteria specifically recommends a biphasic esophagram for unexplained dysphagia 1
• This approach allows comprehensive evaluation of both the pharynx and the entire esophagus in one examination
• The sensation of food being stuck, even when perceived in the throat, may actually be caused by abnormalities in the mid or distal esophagus 1, 2
• Biphasic technique provides superior mucosal detail compared to single-contrast studies while also evaluating function 1

Advantages of Biphasic Esophagram in This Case

• Allows dynamic evaluation of swallowing function, including bolus manipulation, tongue motion, and pharyngeal constrictor motion 1
• Can detect both structural abnormalities (strictures, rings, tumors) and functional disorders (motility problems)
• Has approximately 95% sensitivity for detecting lower esophageal rings and peptic strictures 1
• Can sometimes reveal abnormalities missed by endoscopy, particularly in the case of lower esophageal rings 1
• Less invasive than endoscopy, making it an appropriate first-line test

Clinical Considerations in This Patient

• The mild anemia (Hb 11.6 g/dL) could suggest chronic blood loss, potentially from an esophageal lesion
• The absence of halitosis, vomiting, and fever makes an acute infectious process less likely
• The sensation of food being stuck is a classic symptom that requires thorough evaluation of the entire esophagus

Diagnostic Algorithm

1. First step: Biphasic esophagram (barium meal)

   • If normal: Consider esophageal manometry to evaluate for motility disorders
   • If abnormal with mucosal lesion: Proceed to endoscopy for tissue sampling
   • If abnormal with motility disorder: Confirm with esophageal manometry

2. Second step (based on initial findings):

   • Endoscopy: For tissue sampling if mucosal lesion is suspected
   • Esophageal manometry: If motility disorder is suspected

Common Pitfalls to Avoid

• Assuming the location where the patient perceives symptoms is the actual site of pathology - abnormalities of the distal esophagus can cause referred sensation to the pharynx 1, 2
• Relying solely on patient-reported symptoms without objective testing - up to 55% of patients who aspirate may not exhibit protective cough reflexes 2
• Performing only oropharyngeal evaluation when the problem may be in the esophagus - a study of patients with dysphagia for solids showed that 68% had abnormal esophageal transit 1
• Using single-contrast studies alone, which may miss subtle mucosal lesions that could be detected with double-contrast technique 1

By following this approach, you can efficiently diagnose the cause of the patient's dysphagia while minimizing unnecessary testing and expediting appropriate treatment.