Management of Dysphagia with Normal OGD and HRM
In a 54-year-old female with dysphagia, normal endoscopy, and normal high-resolution manometry, the next step is to perform a barium swallow with solid food challenge (such as a rice meal or bread) to identify subtle structural abnormalities or functional disorders that may only manifest with solid boluses. 1
Rationale for Solid Food Challenge
The British Society of Gastroenterology guidelines specifically recommend standardised meals (such as cooked rice) for patients with dysphagia when no major motility disorder has been discovered using water swallows, as solid food challenges can identify additional diagnoses that water swallows miss 1
Normal HRM with water swallows does not exclude clinically significant dysphagia, as 30-70% of patients with dysmotility and dysphagia may only demonstrate abnormalities during solid food testing 1
The patient should either bring a culprit meal that reproduces symptoms or be provided a standard meal (e.g., standard quantity of cooked rice) during fluoroscopic evaluation 1
Alternative Diagnostic Considerations
Eosinophilic oesophagitis must be excluded if not already done—patients with dysphagia should undergo OGD with biopsies at two levels in the oesophagus even when endoscopy appears visually normal 1
Barium swallow (esophagram) can outline irregularities in the oesophageal lumen and diagnose stricturing lesions that may be missed on endoscopy, particularly subtle rings, webs, or extrinsic compression 1
Consider repeat HRM with provocative maneuvers (rapid drink challenge or multiple rapid swallows) if not already performed, as these can unmask minor disorders of peristalsis that have uncertain clinical significance but may explain symptoms 1
Oropharyngeal vs Esophageal Dysphagia
If the patient's symptoms suggest oropharyngeal dysphagia (coughing while swallowing, nasal regurgitation, wet vocal quality after swallowing, or feeling of food sticking in the throat), refer to a speech-language pathologist for clinical swallowing evaluation 1, 2, 3
Instrumental assessment with videofluoroscopic swallowing study (VFSS) or fiberoptic endoscopic evaluation of swallowing (FEES) should be performed if oropharyngeal dysphagia is suspected, as silent aspiration occurs in up to 55% of patients and cannot be detected by clinical examination alone 1, 2, 3
The distinction between oropharyngeal and esophageal dysphagia should be made through targeted history: difficulty with solids only progressing to liquids suggests mechanical obstruction, while difficulty with both solids and liquids from onset suggests motility disorder 3
Critical Pitfalls to Avoid
Do not dismiss the patient's symptoms simply because initial testing is normal—minor disorders of peristalsis identified on standard HRM have uncertain clinical significance, and 70% of patients with these findings are asymptomatic at 5-year follow-up, suggesting the dysphagia may have another cause 1
Age 54 years places this patient at moderate risk for esophageal malignancy, particularly if there is progressive dysphagia or weight loss—ensure alarm features (weight loss >10% body weight, odynophagia, progressive symptoms) have been thoroughly assessed 4, 3
Referred sensation from distal esophageal or gastric cardia lesions can cause perceived dysphagia in the throat, so ensure the entire esophagus and gastroesophageal junction were adequately visualized during endoscopy 3
When to Reassess or Refer
If solid food barium swallow and repeat endoscopy with biopsies remain normal, consider functional esophageal disorder or hypersensitivity, though this is a diagnosis of exclusion 1
Multidisciplinary evaluation including gastroenterology, speech-language pathology, and potentially psychology may be warranted if no structural or motility abnormality is identified after comprehensive testing 4, 3
Monitor for development of alarm features (progressive symptoms, weight loss, odynophagia) that would necessitate repeat urgent endoscopy 4, 3