From the Guidelines
The best initial test for a 48-year-old patient with dysphagia is an oesophago-gastro-duodenoscopy (OGD) with oesophageal biopsies, as it allows for direct visual inspection and histological sampling to rule out mucosal and structural disorders. This recommendation is based on the British Society of Gastroenterology guidelines for oesophageal manometry and oesophageal reflux monitoring, which suggests that OGD is the preferred investigation in patients with oesophageal dysphagia 1. The guidelines state that 54% of patients presenting with dysphagia had a major abnormality at OGD, with a higher yield in men aged >40 years with associated symptoms such as heartburn, odynophagia, and weight loss.
Key benefits of OGD include:
- Direct visualization of the oesophagus, stomach, and duodenum
- Ability to identify structural abnormalities such as strictures, masses, inflammation, or anatomical variations
- Opportunity for tissue sampling through biopsies to diagnose conditions like eosinophilic oesophagitis, Barrett's esophagus, or malignancy
- Higher diagnostic yield compared to alternative tests like barium swallow studies
In contrast, barium swallow studies may be considered as an alternative initial test in situations where OGD is not possible or feasible, such as in patients with limited healthcare resources or those who are unable or unwilling to undergo endoscopic examination 1. However, OGD remains the preferred first-line diagnostic approach due to its superior diagnostic capability and ability to rule out serious pathology like esophageal cancer, which becomes more prevalent after age 45.
From the Research
Initial Test for Dysphagia
The best initial test for a 48-year-old patient with dysphagia (difficulty swallowing) depends on the origin of the dysphagia, which can be either oropharyngeal or esophageal.
- For esophageal dysphagia, some studies suggest that a video barium esophagram is a good initial test 2.
- However, other studies recommend endoscopy as the initial evaluation for esophageal dysphagia, with barium esophagography as an adjunct 3, 4.
- Endoscopy has been shown to be a highly sensitive test for detecting lesions in patients with dysphagia, with a sensitivity of 98.75% 5.
- The choice of initial test may also depend on the patient's symptoms and medical history, as well as the availability of diagnostic facilities.
Diagnostic Approach
A careful history taking and physical examination are essential in evaluating dysphagia, to distinguish between an oropharyngeal and oesophageal origin 4.
- The three main investigations for dysphagia are endoscopy, barium study, and manometry, with endoscopy also offering therapeutic potential 4.
- Management is largely determined by the eventual diagnosis, often in a multi-disciplinary setting 4.
Considerations
It is important to note that dysphagia can be caused by a number of disorders, including benign or malignant obstruction of the esophagus, inflammatory alterations of the mucosa, or primary esophageal motility disorders 6.
- A discussion about goals of care should be considered before potentially harmful interventions are undertaken, especially in frail older adults with progressive neurologic disease 3.