What is the best course of action for an elderly patient with sudden onset of dysphagia (difficulty swallowing) and odynophagia (painful swallowing) to solids?

Urgent Upper Endoscopy is Required for This Patient

An elderly patient with sudden 2-day onset of dysphagia and odynophagia to solids requires urgent upper endoscopy (esophagogastroduodenoscopy) to rule out esophageal foreign body impaction, food bolus obstruction, or acute esophageal pathology. 1

Why This is an Emergency

The acute presentation (2 days) with both dysphagia and odynophagia to solids represents a potential esophageal emergency requiring immediate evaluation:

• Foreign body or food bolus impaction is the most likely diagnosis given the sudden onset, with typical presentation being acute dysphagia or inability to swallow saliva, along with odynophagia, neck tenderness, and retrosternal pain 1
• Elderly patients are at particularly high risk for esophageal foreign body impaction due to cognitive impairment, poor dentition, and age-related changes in swallowing mechanics 1
• The 2-day timeframe is critical because complications including perforation, mediastinitis, and aspiration pneumonia increase significantly after 24 hours of impaction 1

Immediate Diagnostic Approach

First-Line Imaging Before Endoscopy

Obtain CT scan of the neck, chest, and abdomen immediately if there is any suspicion of perforation or complications, or if plain radiographs are negative but clinical suspicion remains high 1:

• Plain neck and chest radiographs should be obtained first to assess for radiopaque foreign bodies, but the false-negative rate is up to 47% for single-view and up to 85% for food bolus impaction 1
• CT scan has 90-100% sensitivity and 93.7-100% specificity for detecting foreign bodies, particularly food bolus and bone fragments that are radiolucent on plain films 1
• CT is essential if perforation is suspected (fever, subcutaneous emphysema, severe chest pain) 1

Urgent Endoscopy Indications

Proceed directly to urgent upper endoscopy for both diagnosis and therapeutic intervention 1:

• Endoscopy allows direct visualization and immediate removal of impacted foreign bodies or food bolus 1
• Do not delay endoscopy beyond 24 hours in patients with complete esophageal obstruction (inability to swallow saliva, drooling) as perforation risk increases dramatically 1
• The elderly are at higher risk for complications during prolonged impaction due to tissue friability and comorbidities 1

Critical Differential Diagnoses to Exclude

While foreign body impaction is most likely given the acute presentation, consider these alternative diagnoses:

Acute Esophageal Pathology

• Esophageal perforation or rupture (Boerhaave syndrome) presents with sudden severe chest pain, odynophagia, and subcutaneous emphysema 1
• Acute infectious esophagitis (Candida, HSV, CMV) can cause sudden odynophagia, particularly in immunocompromised elderly patients 1
• Medication-induced esophagitis from bisphosphonates, NSAIDs, or potassium chloride can cause acute odynophagia 1

Mechanical Obstruction

• Esophageal stricture typically presents with progressive dysphagia, but acute food impaction can occur at a stricture site 1, 2
• Esophageal malignancy usually has a more insidious onset over weeks to months, not 2 days 3, 4

What Happens After Endoscopy

If Foreign Body or Food Bolus is Found and Removed

• Monitor for 24 hours for signs of perforation (fever, chest pain, subcutaneous emphysema) even after successful removal 1
• Investigate underlying cause: obtain barium esophagram 48-72 hours later to evaluate for stricture, ring, or mass that predisposed to impaction 2, 5
• If stricture or Schatzki ring is identified, endoscopic dilation can be performed at a subsequent procedure 6, 5

If No Foreign Body is Found

• Consider videofluoroscopic swallow study (VFSS) or fiberoptic endoscopic evaluation of swallowing (FEES) to assess for oropharyngeal dysphagia with aspiration risk 1, 3
• The sudden onset makes neurologic causes less likely, but acute stroke or other neurologic events must be excluded 1, 5
• Up to 55% of elderly patients with aspiration have silent aspiration without protective cough, making instrumental assessment critical 3

If Esophagitis is Found

• Treat empirically with high-dose proton pump inhibitor (PPI) twice daily for infectious or reflux esophagitis 6
• Obtain biopsies to differentiate between reflux, eosinophilic, infectious, or medication-induced esophagitis 4, 5
• Discontinue any potentially caustic medications (bisphosphonates, NSAIDs, potassium) 5

Common Pitfalls to Avoid

• Do not assume this is simple GERD or age-related dysphagia given the acute 2-day onset with odynophagia—this presentation demands urgent evaluation 1, 3
• Do not start empiric PPI therapy and observe without first excluding foreign body impaction or acute esophageal pathology requiring immediate intervention 1
• Do not order barium esophagram as the first test if foreign body impaction is suspected, as this can complicate subsequent endoscopy and obscure visualization 1
• Do not delay evaluation beyond 24 hours in elderly patients, as tissue friability and comorbidities increase perforation risk with prolonged impaction 1
• Do not discharge the patient without 24-hour observation after foreign body removal, as delayed perforation can occur 1

Nutritional and Aspiration Risk Management

While awaiting endoscopy (which should occur within hours, not days):

• Keep patient NPO (nothing by mouth) until esophageal patency is confirmed 1
• Administer IV fluids to prevent dehydration 1
• Monitor for signs of aspiration pneumonia (fever, cough, hypoxia) as elderly patients with esophageal obstruction are at high risk for aspiration of retained secretions 1, 3
• Consider nasogastric tube placement only after endoscopy confirms no perforation, if prolonged NPO status is anticipated 1