What is the investigation of choice for a patient experiencing dysphagia (difficulty swallowing) to liquids?

Investigation of Choice for Dysphagia to Liquids

Upper GI endoscopy (esophagogastroduodenoscopy/OGD) is the investigation of choice for a patient presenting with dysphagia to liquids, as it allows direct visualization of the esophageal mucosa and enables tissue sampling to diagnose underlying pathology. 1

Diagnostic Approach Algorithm

1. First-line investigation: Upper GI endoscopy with biopsies

   • Provides direct visual inspection of the esophagus
   • Allows histological sampling to rule out mucosal disorders
   • Can diagnose and potentially treat structural abnormalities
   • Higher diagnostic yield in patients with dysphagia (54% of patients have major abnormalities detectable by OGD) 1
   • Biopsies should be taken at two levels in the esophagus to exclude conditions like eosinophilic esophagitis 1

2. Second-line investigation: Barium swallow

   • Indicated when endoscopy is not possible or inconclusive
   • Useful for further evaluation of structural disorders
   • Better for assessing functional abnormalities of swallowing
   • Particularly valuable for oropharyngeal dysphagia 1, 2

3. Additional specialized testing (based on initial findings)

   • Modified barium swallow: For suspected oropharyngeal dysphagia 1, 2
   • High-resolution manometry: For suspected motility disorders 1
   • Videofluoroscopic swallow study (VFSS): Gold standard for evaluating pharyngeal phase of swallowing 2
   • CT scan: Not indicated as initial imaging but useful for suspected complications 1, 2

Evidence-Based Rationale

The British Society of Gastroenterology strongly recommends endoscopy as the preferred investigation for esophageal dysphagia 1. This recommendation is supported by evidence showing that 54% of patients presenting with dysphagia have major abnormalities detectable by OGD, with higher yield in men over 40 years with associated symptoms like heartburn, odynophagia, and weight loss 1.

While barium studies are valuable, particularly for assessing functional aspects of swallowing, they are recommended as second-line or complementary tests when endoscopy cannot be performed or when further assessment of structural abnormalities is needed 1, 2.

Important Clinical Considerations

• Dysphagia specifically to liquids (rather than solids) may suggest a motility disorder rather than a mechanical obstruction, but endoscopy remains the first step to rule out structural causes 1
• Silent aspiration is common in neurological disorders, making instrumental evaluation necessary as clinical evaluation alone may be inadequate 2
• For patients with suspected oropharyngeal dysphagia, a modified barium swallow performed with a speech-language pathologist may be particularly valuable 1

Pitfalls to Avoid

• Relying solely on imaging without direct visualization of the esophageal mucosa may miss important mucosal pathology
• Failing to obtain biopsies during endoscopy, which are essential to diagnose conditions like eosinophilic esophagitis
• Using CT as first-line investigation, as it does not adequately assess esophageal mucosa and motility 1
• Delaying proper evaluation, as dysphagia is associated with higher risk of aspiration pneumonia, malnutrition, and mortality 2

The answer is A. Upper GI endoscopy.