From the Guidelines
To assess a 67-year-old male with complaints of dysphagia at his primary care physician visit, I recommend starting with a thorough history and physical examination, followed by initial diagnostic testing, and considering prompt referral to gastroenterology for possible endoscopy if concerning symptoms are present, as indicated by the American College of Physicians best practice advice 1. When evaluating the patient, it is essential to ask about the duration of symptoms, whether the difficulty occurs with solids, liquids, or both, and if there's associated pain, weight loss, regurgitation, or cough during eating. Inquire about risk factors like smoking, alcohol use, and family history of gastrointestinal cancers. Perform a focused physical exam including vital signs, oral cavity inspection, neck examination for masses, and neurological assessment of cranial nerves involved in swallowing. Some key points to consider in the assessment include:
- The patient's age and symptoms, such as dysphagia, which may indicate a need for upper endoscopy, as recommended by the American College of Physicians 1
- The presence of alarm symptoms, such as bleeding, anemia, weight loss, and recurrent vomiting, which may also indicate a need for upper endoscopy 1
- The importance of a systematic approach to diagnosis and management, considering various causes of dysphagia, including gastroesophageal reflux disease, esophageal strictures, motility disorders, or oropharyngeal dysfunction Initial diagnostic testing should include basic laboratory work, such as a complete blood count (CBC) and comprehensive metabolic panel, and referral for a barium swallow study or modified barium swallow depending on the suspected etiology. For patients with concerning symptoms like weight loss, persistent dysphagia, or age over 50, prompt referral to gastroenterology for possible endoscopy is warranted to rule out malignancy, as supported by the American College of Physicians best practice advice 1. Additionally, guidelines from the Canadian stroke best practice recommendations suggest that patients should be screened for swallowing deficits using a valid screening tool, and abnormal results should prompt a referral to a speech-language pathologist or other trained dysphagia clinician for more detailed assessment and management 1.
From the Research
Assessment of Dysphagia
To assess a 67-year-old male with complaints of dysphagia, the following steps can be taken:
- Evaluate the patient's symptoms, including the duration and severity of dysphagia, as well as any associated symptoms such as heartburn, regurgitation, or weight loss 2
- Perform a thorough clinical examination to identify any potential causes of dysphagia, such as gastroesophageal reflux disease (GERD) or mechanical obstruction of the esophagus 3
- Order diagnostic tests, including:
- Upper endoscopy to visualize the esophagus and identify any structural defects or esophagitis 4, 2
- Barium swallow with fluoroscopy to demonstrate structural defects and evaluate esophageal motility 3, 2
- High-resolution manometry to evaluate esophageal motility and lower esophageal sphincter pressure 2
- Ambulatory pH monitoring to evaluate acid reflux and its correlation with symptoms 2, 5
Differential Diagnosis
The differential diagnosis of dysphagia may include:
- Achalasia
- Diffuse esophageal spasm
- Mechanical obstruction of the esophagus due to rings, webs, strictures, or benign or malignant tumors 3
- GERD, which can cause dysphagia, odynophagia, and other symptoms 4, 2, 6
Management
The management of dysphagia will depend on the underlying cause, but may include:
- Pharmacologic treatment, such as proton pump inhibitors (PPIs) for GERD 4, 6
- Lifestyle modifications, such as dietary changes and weight loss 6
- Surgical or endoscopic interventions, such as fundoplication or radiofrequency ablation, for patients with severe GERD or mechanical obstruction of the esophagus 4, 6, 5