What is the best initial step before proceeding to surgery for a 76-year-old man with chronic dysphagia, retrosternal chest pain, choking, postprandial cough, sensation of food sticking, and regurgitation?

Best Initial Diagnostic Test Before Surgery for Chronic Dysphagia

OGD with biopsy (option D) is the best initial step before proceeding to surgery for a 76-year-old man with chronic dysphagia, retrosternal chest pain, choking, postprandial cough, sensation of food sticking, and regurgitation. 1

Rationale for OGD with Biopsy

1. High Diagnostic Yield:

   • The American Gastroenterological Association and European Society of Gastrointestinal Endoscopy recommend esophagogastroduodenoscopy (OGD) with biopsies as the initial diagnostic step in patients with progressive dysphagia, particularly in elderly patients, due to its high diagnostic yield (54%) 1
   • Direct visualization allows for tissue diagnosis which is crucial before any surgical intervention 1

2. Elderly Patient Considerations:

   • In patients aged 75 years and older, esophageal and gastric malignancies were detected in 6.4-18% of cases, making direct visualization essential 2
   • OGD is a safe procedure with high diagnostic yield in elderly patients, with complications due to the procedure itself being rare 2

3. Symptom Pattern Analysis:

   • The patient's symptoms (retrosternal chest pain, choking, postprandial cough, food sticking, regurgitation) suggest possible structural abnormalities that require direct visualization 3
   • These symptoms could indicate esophageal cancer, which requires biopsy for diagnosis 1

Why Other Options Are Less Appropriate

1. 24-hour Esophageal Acid Monitoring (Option A):

   • While useful for GERD diagnosis, this should only be performed after structural abnormalities have been ruled out 1
   • The American College of Gastroenterology recommends 24-hour pH monitoring only after initial testing has ruled out structural abnormalities 1

2. Rigid/Flexible Esophagoscopy (Option B):

   • This is essentially a component of OGD but without the comprehensive evaluation of the stomach and duodenum, making it less complete than OGD with biopsy 3

3. Esophageal Manometry (Option C):

   • Manometry is indicated only if a motility disorder is suspected after initial testing 1
   • The British Society of Gastroenterology guidelines state that manometry should be performed to rule out LOS dysfunction before surgery, but it is not the first-line test 3
   • Manometry alone cannot detect mucosal lesions or allow for tissue sampling 3

Diagnostic Algorithm for Chronic Dysphagia

1. First-line: OGD with biopsy

   • Allows direct visualization and tissue diagnosis
   • Rules out malignancy and structural abnormalities
   • High diagnostic yield in elderly patients

2. Second-line (based on OGD findings):

   • If OGD shows structural abnormality or is normal/inconclusive: Barium esophagram (biphasic or single-contrast)
   • If motility disorder is suspected: Esophageal manometry
   • If GERD-related dysphagia is suspected and structural causes ruled out: 24-hour pH monitoring

Important Clinical Considerations

• In elderly patients with progressive dysphagia, malignancy must be excluded first before considering other diagnoses 1, 2
• The Society of American Gastrointestinal and Endoscopic Surgeons recommends direct visualization and tissue diagnosis before any surgical intervention 1
• Esophageal cancer risk increases with age, making tissue diagnosis crucial in a 76-year-old patient 2
• The combination of symptoms (retrosternal chest pain, choking, food sticking, regurgitation) in an elderly patient raises concern for serious pathology requiring direct visualization 3, 4

By performing OGD with biopsy first, you ensure proper diagnosis before proceeding to surgery, potentially avoiding unnecessary procedures and ensuring appropriate surgical planning if needed.