What is the most appropriate next step for a 48-year-old female smoker with 4 months of dysphagia (difficulty swallowing) for solid foods, but not liquids, who experiences a sensation of food being stuck and occasionally regurgitates, with the sensation of food being lodged at the suprasternal notch?

From the Guidelines

The most appropriate next step for this 48-year-old female smoker with progressive solid food dysphagia is an upper endoscopy (esophagogastroduodenoscopy or EGD). This procedure should be performed promptly to directly visualize the esophagus and identify the cause of her symptoms. Her presentation of solid food dysphagia for 4 months with preservation of liquid swallowing, sensation of food getting stuck at the suprasternal notch, and episodes of regurgitation strongly suggests a mechanical obstruction of the esophagus. Given her age and smoking history, esophageal cancer must be ruled out as a priority. Other possible diagnoses include a benign esophageal stricture, esophageal ring or web, or achalasia. Upper endoscopy allows for direct visualization of any obstructing lesion, tissue sampling if needed, and potential therapeutic intervention such as dilation if a benign stricture is found. While a barium swallow study could be considered, endoscopy is preferred as the initial test because it offers both diagnostic and therapeutic capabilities in a single procedure, as supported by the guidelines from the American College of Physicians 1. The patient should be advised to continue with a modified diet of soft or liquid foods until the procedure can be performed to minimize the risk of food impaction.

The decision to perform an upper endoscopy is further supported by the UK guidelines on oesophageal dilatation in clinical practice, which recommend endoscopy as the initial diagnostic test for patients with dysphagia 1. Additionally, the guidelines emphasize the importance of tissue diagnosis prior to dilatation, which can be obtained during the endoscopy procedure. The guidelines also recommend that patients with suspected achalasia undergo detailed assessment to confirm the diagnosis and exclude occult carcinoma, which can be done during the endoscopy procedure.

In terms of specific considerations for the patient's care, the guidelines recommend that patients with esophageal strictures or other obstructing lesions be advised to avoid foods that may exacerbate their symptoms, and to follow a modified diet until the underlying condition is treated. The patient should also be informed about the potential risks and benefits of the endoscopy procedure, including the risk of perforation or bleeding, and the potential need for additional procedures such as dilation or stent placement.

Overall, the most appropriate next step for this patient is an upper endoscopy, which will allow for direct visualization of the esophagus, tissue sampling, and potential therapeutic intervention, and will help to rule out esophageal cancer and other possible diagnoses.

From the Research

Symptoms and Potential Causes

• The patient is experiencing dysphagia (difficulty swallowing) for solid foods, but not liquids, with a sensation of food being stuck and occasional regurgitation, indicating a potential esophageal stricture 2, 3, 4.
• The sensation of food being lodged at the suprasternal notch suggests an obstruction in the esophagus, which could be due to a benign or malignant stricture 3, 4.

Diagnostic and Treatment Options

• Endoscopic management is a common approach for treating esophageal strictures, including dilation therapy, steroid injection, incisional therapy, and stent placement 2, 3, 4.
• The choice of treatment depends on the type and severity of the stricture, as well as the patient's overall health and medical history 3, 4.
• Endoscopic dilation is often the first-line treatment for benign esophageal strictures, while stent placement may be considered for malignant strictures or refractory benign strictures 3, 4.

Next Steps

• The patient should undergo an upper gastrointestinal endoscopy to visualize the esophagus and diagnose the cause of the dysphagia 5.
• Based on the findings, the patient may require endoscopic treatment, such as dilation or stent placement, to relieve the obstruction and improve swallowing function 2, 3, 4.
• The patient's smoking history and age should be taken into consideration when developing a treatment plan, as these factors may impact the risk of complications and the effectiveness of treatment 2, 3, 4.