From the Guidelines
The initial workup for dysphagia should begin with a thorough history and physical examination, followed by diagnostic tests such as fluoroscopy barium swallow modified or fluoroscopy biphasic esophagram, depending on the suspected etiology, as recommended by the American College of Radiology 1. The history should focus on the nature of the swallowing difficulty (solids, liquids, or both), duration, progression, associated symptoms, and risk factors.
- A modified barium swallow study or videofluoroscopy is often the first-line imaging test for oropharyngeal dysphagia with an attributable cause, as it can evaluate the oral, pharyngeal, and esophageal phases of swallowing 1.
- For unexplained oropharyngeal dysphagia, fluoroscopy biphasic esophagram is usually appropriate for the initial imaging 1.
- Physical examination should include assessment of oral cavity, cranial nerves, and neck examination. Following this, diagnostic tests should be ordered based on the suspected etiology.
- For retrosternal dysphagia in immunocompetent patients, fluoroscopy biphasic esophagram is usually appropriate for the initial imaging 1.
- For retrosternal dysphagia in immunocompromised patients, fluoroscopy biphasic esophagram is also usually appropriate for the initial imaging 1. Basic laboratory tests including complete blood count, comprehensive metabolic panel, and thyroid function tests can help identify systemic causes. This stepwise approach helps differentiate between oropharyngeal and esophageal dysphagia, which have different etiologies and management strategies, allowing for prompt diagnosis and appropriate treatment.
From the Research
Initial Workup for Dysphagia
The initial workup for dysphagia involves a comprehensive evaluation, including physical examination and subsequent work-up, as outlined in 2.
- Evaluating a patient with dysphagia can be complex and requires a practical approach.
- The evaluation process includes a physical examination and subsequent work-up.
Diagnostic Tools
Several diagnostic tools are used in the initial workup for dysphagia, including:
- Modified Barium Swallow (MBS) procedure, which enables appropriate diagnosis and treatment of dysphagia, as described in 3.
- Barium swallow, which remains a useful investigation in esophageal dysphagia, although its role has evolved due to advancements in other diagnostics, as discussed in 4.
- Chest CT scan, which is important for correct diagnosis of achalasia in the primary care setting, as highlighted in 5.
- Fiberoptic endoscopic evaluation of swallowing (FEES) and MBS study, which have different advantages and disadvantages, as compared in 6.
Importance of Timely Diagnostic Tests
Performing diagnostic tests, such as barium swallow and chest CT scan, in a timely fashion is crucial to avoid delayed diagnosis of achalasia, as emphasized in 5.
- Delayed diagnosis can impair patients' quality of life.
- Barium swallow test and chest CT scan have higher sensitivities than endoscopy for diagnosing achalasia.