From the Guidelines
For a patient in their 20s with recurrent dysphagia episodes that are not responding to proton pump inhibitor (PPI) therapy, the next best step is to perform an upper endoscopy. This recommendation is based on the best practice advice from the American College of Physicians, which suggests that upper endoscopy is indicated in patients with typical GERD symptoms that persist despite a therapeutic trial of 4 to 8 weeks of twice-daily proton-pump inhibitor therapy 1. The patient's symptoms of recurrent dysphagia, which have not been relieved by PPI therapy, warrant further investigation with endoscopy to rule out other causes of dysphagia, such as strictures, webs, rings, or even malignancy.
Key Points to Consider
- The patient's age and lack of response to acid suppression suggest the possibility of eosinophilic esophagitis, which can be diagnosed through endoscopy and biopsy 1.
- Endoscopy allows for direct visualization of the esophageal mucosa and permits biopsies to confirm the diagnosis, which is essential for guiding treatment 1.
- Other diagnostic tests, such as barium studies or manometry, may not provide the necessary tissue diagnosis or may not be the first choice for this presentation.
- The American College of Physicians recommends upper endoscopy for patients with GERD symptoms that persist despite PPI therapy, as well as for those with alarm symptoms such as dysphagia 1.
Recommendations for Next Steps
- Perform an upper endoscopy to rule out other causes of dysphagia and to guide treatment.
- Consider biopsy during endoscopy to diagnose conditions such as eosinophilic esophagitis.
- Develop a treatment plan based on the findings of the endoscopy and biopsy results.
From the Research
Next Best Steps for Dysphagia Diagnosis and Treatment
Given the patient's history of recurrent dysphagia episodes and lack of relief from Proton Pump Inhibitors (PPI), the following steps can be considered:
- Detailed history taking to identify any underlying conditions or recent developments that could be contributing to the dysphagia 2
- Endoscopy to evaluate for structural abnormalities, including malignancy, and to obtain esophageal biopsies to check for conditions like eosinophilic esophagitis (EoE) 2
- High-resolution manometry (HRM) to evaluate for motility disorders, such as achalasia, and the use of the Chicago Classification for systematic diagnosis 2
- Functional lumen imaging probe (FLIP) to measure esophageal distensibility and identify motility abnormalities 2
Considerations for Esophageal Strictures
If the patient is found to have an esophageal stricture, the following management options can be considered:
- Dilation therapy for benign strictures, which is the cornerstone of management 3, 4
- Stent placement for malignant strictures, with options for managing complications like tissue in- or overgrowth, stent migration, and food obstruction 3
- Alternative approaches for refractory or recurrent benign strictures, including steroid injections, incisional therapy, and temporary stent placement 3, 4
Importance of Upper Endoscopy
An upper endoscopy (EGD) can be beneficial before proceeding with other diagnostic tests, such as transesophageal echocardiography (TEE), to evaluate the safety of the procedure and identify any esophageal abnormalities that may preclude the passage of a blind probe 5