How to manage abdominal pain with intermittent dysphagia in a patient with no evidence of obstruction and normal findings on Esophagogastroduodenoscopy (EGD) and colonoscopy?

Management of Abdominal Pain with Intermittent Dysphagia and Normal Endoscopic Findings

For patients with abdominal pain and intermittent dysphagia with normal EGD and colonoscopy findings, a functional esophageal disorder is likely present and should be treated with a combination of neuromodulators, cognitive behavioral therapy, and lifestyle modifications. 1

Diagnostic Considerations

• Normal EGD and colonoscopy findings with no obstruction suggest a functional esophageal disorder rather than organic pathology 1
• The combination of abdominal pain with food getting stuck intermittently points to possible visceral hypersensitivity or esophageal motility issues 1
• These symptoms may represent a form of functional dysphagia where innocuous stimuli are perceived as painful (allodynia) 1

Initial Management Approach

Step 1: Trial of Acid Suppression

• Despite normal endoscopic findings, a 4-8 week empiric trial of single-dose PPI therapy (omeprazole 20mg daily) is recommended as first-line treatment 1, 2
• This approach helps rule out borderline GERD that may not have been evident on endoscopy 1
• If partial response is achieved, consider increasing to twice daily PPI (though this is not FDA approved) 1, 2

Step 2: For Persistent Symptoms After PPI Trial

• If symptoms persist despite PPI therapy, consider functional esophageal disorder as the primary diagnosis 1
• Discontinue PPI therapy if no benefit is observed after adequate trial 1
• Consider high-resolution manometry to evaluate for esophageal motility disorders that may have been missed on standard endoscopy 1

Advanced Management Options

Neuromodulators

• Low-dose tricyclic antidepressants (TCAs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) can be prescribed by gastroenterologists for pain modulation 1
• These medications address central sensitization mechanisms that maintain and amplify pain perception 1
• Start with low doses and titrate slowly to minimize side effects 1

Behavioral Interventions

• Cognitive behavioral therapy (CBT) has demonstrated efficacy for functional esophageal disorders 1
• Gut-directed hypnotherapy can be particularly effective for patients with visceral hypersensitivity 1
• Breathing techniques should be taught as baseline therapy 1

Lifestyle Modifications

• Implement aggressive lifestyle modifications including:
  • Weight management if applicable 1
  • Dietary modifications to avoid foods that trigger symptoms 1
  • Stress reduction techniques 1
  • Eating smaller, more frequent meals and avoiding eating close to bedtime 1

Special Considerations

• Patients with a history of chronic pain, early-life adversity, trauma, or poor coping styles are at higher risk for developing chronic pain syndromes 1
• Setting expectations early about the multifactorial nature of pain perception is important for therapeutic alliance 1
• Explain to patients that the peripheral factors that initiated pain may differ from the central factors that maintain it 1

When to Consider Additional Testing

• If symptoms worsen or new alarm symptoms develop (weight loss, progressive dysphagia, hematemesis), repeat endoscopic evaluation 3
• Consider prolonged ambulatory pH monitoring if GERD remains a clinical suspicion despite normal endoscopy 1
• For persistent dysphagia with normal endoscopy, high-resolution manometry may identify subtle motility disorders 1

Common Pitfalls to Avoid

• Assuming normal endoscopy excludes all pathology - functional disorders require active management 1
• Continuing PPIs indefinitely without documented benefit 1
• Failing to address psychological factors that may contribute to symptom perception 1
• Not recognizing that visceral hypersensitivity can cause significant symptoms despite normal structural findings 1