What's the next step in managing a 20-year-old female with intermittent dysphagia (difficulty swallowing) and a normal barium meal study, currently on proton pump inhibitor (PPI) and antacid with amitriptyline (tricyclic antidepressant)?

Management of Dysphagia in a 20-Year-Old Female with Normal Barium Study

The next step in management should be esophageal manometry to evaluate for esophageal motility disorders, as this is the most appropriate diagnostic test for a young patient with persistent dysphagia despite normal barium study and current medication trial. 1

Current Clinical Picture Analysis

The patient presents with:

• 20-year-old female
• Intermittent sensation of food getting stuck in throat
• Normal barium meal study (no obstruction)
• No vomiting, bad breath, or fever
• Currently on PPI, antacid, and amitriptyline

Diagnostic Algorithm

1. Esophageal Manometry (High-Resolution)

   • This is the next appropriate step to evaluate esophageal motility disorders that may mimic or contribute to dysphagia 1, 2
   • Should include solid swallows during the procedure to replicate the presenting symptoms 1
   • Will help identify potential motility disorders such as:
     • Ineffective esophageal motility
     • Esophageal spasm
     • Achalasia-type patterns
     • Functional esophageal disorders

2. If Manometry Normal → Consider Upper Endoscopy with Biopsies

   • To evaluate for:
     • Eosinophilic esophagitis (EoE) - a common cause of dysphagia in young adults 1
     • Subtle mucosal abnormalities not detected on barium study
     • Histological evidence of inflammation

Medication Management Considerations

Current Regimen Assessment

1. PPI Therapy

   • Reassess appropriateness as there's no clear evidence of GERD 1
   • Consider discontinuation if no objective evidence of GERD is found on further testing 1
   • If symptoms persist beyond 8-12 weeks without evidence of GERD, PPI should be discontinued 1

2. Amitriptyline

   • May be beneficial for functional esophageal disorders 3, 4
   • Studies show 47-56% improvement in functional chest pain with amitriptyline 3
   • Continue if esophageal manometry suggests functional disorder

Treatment Modifications Based on Findings

• If Motility Disorder Identified:

  • Adjust treatment based on specific disorder
  • Consider specialized therapy (e.g., botulinum toxin for spasm)
  • Continue amitriptyline for functional disorders

• If Eosinophilic Esophagitis:

  • Switch to topical steroids (fluticasone or budesonide) 1
  • Consider dietary modifications
  • Discontinue PPI if no concurrent GERD

• If Functional Dysphagia:

  • Continue amitriptyline as it has shown benefit in functional esophageal disorders 3
  • Consider cognitive behavioral therapy or gut-directed hypnotherapy 1
  • Discontinue PPI if no evidence of acid reflux 1

Important Clinical Considerations

• Age and Presentation: The young age and intermittent nature of symptoms without warning signs (weight loss, progressive dysphagia) make a functional disorder more likely 2

• Dysphagia with Normal Barium Study: This combination strongly suggests either:

  • Early/mild eosinophilic esophagitis
  • Esophageal motility disorder
  • Functional esophageal disorder 1, 2

• Common Pitfalls to Avoid:

  • Continuing PPI without objective evidence of GERD leads to unnecessary medication exposure 1
  • Attributing symptoms to GERD without proper testing can delay diagnosis of other conditions 1
  • Failing to consider eosinophilic esophagitis, which is increasingly recognized in young adults with dysphagia 1
  • Relying solely on barium studies which may miss subtle motility disorders 1, 2

By following this approach, you can identify the underlying cause of the patient's dysphagia and tailor treatment appropriately to improve symptoms and quality of life.