What is the diagnostic management for a patient with progressive dysphagia and odynophagia, suspected of having esophageal stricture, with a history of Gastroesophageal Reflux Disease (GERD)?

Diagnostic Management for Ruling Out Esophageal Stricture

In a patient with progressive dysphagia and odynophagia with known GERD, proceed directly to upper endoscopy with biopsy as the first-line diagnostic test to identify stricture, assess for Barrett's esophagus or malignancy, and exclude eosinophilic esophagitis. 1

Initial Diagnostic Approach

Upper Endoscopy is the Primary Test

• Endoscopy should be performed immediately in any patient presenting with dysphagia (an alarm symptom), regardless of response to PPI therapy. 1, 2
• During endoscopy, document the stricture location, length, degree of narrowing, presence of angulation, and mucosal appearance to assess technical difficulty and perforation risk. 1
• Obtain multiple esophageal biopsies (at least 5 specimens) even from normal-appearing mucosa to exclude eosinophilic esophagitis, which can present with dysphagia and stricture formation but appears endoscopically normal in some cases. 1
• Biopsies from the stricture site itself are essential to exclude malignancy and confirm peptic etiology in GERD-related strictures. 3, 4

Role of Barium Esophagram

• Barium esophagram is complementary to endoscopy and particularly valuable when strictures are tight, long, complex, or prevent endoscope passage. 1, 5
• Contrast studies provide anatomical detail about stricture length, angulation, presence of diverticula or hiatus hernia, and can detect proximal pathology (pharyngeal pouches, webs) that increase perforation risk. 1, 5
• The pattern and location of strictures on barium study can suggest etiology: distal strictures with sacculations suggest peptic origin, while mid-esophageal strictures may indicate Barrett's, radiation, or caustic injury. 5

When Endoscopy is Normal or Inconclusive

Proceed to Esophageal Manometry

• If endoscopy shows no mechanical obstruction but dysphagia persists, esophageal manometry is indicated to exclude achalasia or other major motility disorders that can mimic stricture. 1
• Manometry serves to localize the lower esophageal sphincter for potential pH probe placement and evaluate peristaltic function. 1
• High-resolution manometry has superior sensitivity for detecting atypical presentations of achalasia and distal esophageal spasm compared to conventional manometry. 1

Consider pH Monitoring After Normal Endoscopy and Manometry

• Ambulatory pH monitoring (PPI withheld for 7 days) is indicated only after normal endoscopy and manometry to determine if symptoms are acid-related. 1
• Wireless pH monitoring has superior sensitivity due to 48-hour recording period compared to catheter-based studies. 1

Critical Diagnostic Pitfalls to Avoid

Do Not Miss Eosinophilic Esophagitis

• Eosinophilic esophagitis commonly presents with dysphagia and food impaction in adults, and can cause strictures that appear similar to peptic strictures. 1
• This diagnosis requires tissue confirmation and cannot be made by endoscopic appearance alone—multiple biopsies are mandatory. 1
• EE symptoms are unresponsive or only partially responsive to acid suppression, which may mislead clinicians if biopsies are not obtained. 1

Assess for Malignancy Risk

• In patients with long-standing GERD (>5 years), particularly men over 50, strictures may harbor occult malignancy or Barrett's esophagus. 2
• Weight loss, progressive dysphagia, and odynophagia are the alarm features with best performance for identifying esophageal malignancy. 1
• Tissue diagnosis should be obtained before dilation when endoscopic features suggest malignancy or when strictures are tight. 1

Recognize Achalasia Masquerading as Stricture

• Patients with suspected achalasia based on clinical presentation require manometry to confirm diagnosis before any intervention, as dilation without diagnosis confirmation can be harmful. 1
• Endoscopic assessment of the gastroesophageal junction should carefully exclude malignancy, with consideration of CT scanning or endosonography if neoplasm is suspected. 1

Diagnostic Algorithm Summary

1. First: Upper endoscopy with multiple biopsies (excludes mechanical obstruction, malignancy, eosinophilic esophagitis) 1
2. Consider barium esophagram if stricture prevents endoscope passage or for anatomical detail in complex cases 1, 5
3. Second: Esophageal manometry if endoscopy normal but dysphagia persists (excludes achalasia, motility disorders) 1
4. Third: pH monitoring off PPI if endoscopy and manometry normal (determines acid exposure) 1

Special Considerations in GERD Patients

• Patients with known GERD developing new dysphagia require endoscopy regardless of PPI compliance, as this represents a complication requiring evaluation. 2, 6
• Peptic strictures are the most common benign strictures in the distal esophagus and typically respond to dilation plus acid suppression. 5, 4
• Following diagnosis and treatment of severe erosive esophagitis or stricture, repeat endoscopy after 2 months of PPI therapy assesses healing and screens for Barrett's esophagus. 2