From the Guidelines
The workup for dysphagia should begin with an endoscopy with oesophageal biopsies to rule out and treat mucosal and structural disorders, as recommended by the British Society of Gastroenterology guidelines 1. This approach is supported by the fact that oesophago-gastro-duodenoscopy (OGD) allows for direct visual inspection of the oesophagus and histological sampling, with 54% of patients presenting with dysphagia having a major abnormality at OGD 1. Key points to consider in the workup for dysphagia include:
- OGD is the preferred investigation, especially in men aged >40 years with heartburn, odynophagia, and weight loss occurring in association with dysphagia 1
- Biopsy at two levels in the oesophagus should be performed to exclude eosinophilic oesophagitis in the absence of a mucosal or structural cause for symptoms 1
- Contrast radiology, such as a barium swallow, can be a useful adjunct to endoscopic examination, particularly in situations where endoscopy is not possible or in countries with limited healthcare resources 1
- The specific sequence of tests depends on the patient's presentation, with red flag symptoms like weight loss, bleeding, or progressive dysphagia warranting urgent endoscopy to rule out malignancy. It is essential to note that the British Society of Gastroenterology guidelines provide a strong recommendation with moderate GRADE evidence for this approach 1.
From the Research
Diagnostic Approach to Dysphagia
- Evaluating a patient with dysphagia can be complex, and a practical approach to evaluation, physical examination, and subsequent work-up is necessary 2.
- The clinical history is of paramount importance in delineating the cause of dysphagia, and a structured history of dysphagia and its associated symptoms should be taken 3.
Role of Diagnostic Tests
- Barium esophagography is a useful diagnostic test for evaluating patients with dysphagia, as it permits assessment of morphologic abnormalities in the pharynx and esophagus, oropharyngeal swallowing function, esophageal motility, and gastroesophageal reflux 4, 5.
- A timed barium swallow (TBS) protocol provides a more standardized assessment of esophageal emptying, but does not evaluate peristalsis 5.
- Barium swallow may have higher sensitivity than endoscopy for detecting subtle strictures, and has a role in evaluating manometric esophagogastric junction outflow obstruction 5.
- Fibreoptic endoscopic evaluation of swallowing (FEES) and videofluoroscopy are also useful diagnostic tests, and there is no significant difference regarding their diagnostic efficacy 3.
Investigation of Dysphagia
- A barium swallow should be performed in dysphagia following bariatric or anti-reflux surgery, to assess for both structural and functional postsurgical abnormality 5.
- High-resolution manometry is a useful diagnostic test for diagnosing achalasia, but barium swallow can help secure the diagnosis in cases of equivocal manometry 5.
- Endoscopy is a sophisticated technique for evaluating patients with gastroesophageal reflux disease (GERD), but esophagography and esophagoscopy are complementary procedures that provide a more comprehensive and therapeutically actionable plan for patients with GERD than either diagnostic test alone 4.