What should be done for someone experiencing difficulty swallowing, possibly with a history of Gastroesophageal Reflux Disease (GERD)?

Difficulty Swallowing: Evaluation and Management

Dysphagia in the context of GERD is an alarm symptom that mandates prompt upper endoscopy to rule out serious complications including esophageal cancer, stricture, erosive esophagitis, or Barrett esophagus. 1

Immediate Clinical Assessment

Determine the pattern of dysphagia to guide diagnosis:

• Progressive dysphagia starting with solids only, then progressing to liquids indicates mechanical obstruction (stricture, cancer, rings) 2
• Simultaneous dysphagia to both solids and liquids from onset strongly suggests a motor/motility disorder (achalasia, diffuse esophageal spasm, neurologic disease) rather than mechanical obstruction 2
• Worsening dysphagia in GERD patients requires investigation as it may indicate peptic stricture (occurs in 8% of adults with repaired esophageal conditions), esophageal cancer, or eosinophilic esophagitis 1, 3

Assess for additional alarm features that increase urgency:

• Pain on swallowing (odynophagia) 1
• Anemia 1
• Weight loss 1
• Hematemesis 1
• Recurrent vomiting 1

Diagnostic Workup

The appropriate next imaging study is a biphasic esophagram (barium swallow), which has 96% sensitivity for esophageal cancer and 80-89% sensitivity for motility disorders like achalasia. 2 This study can detect both structural abnormalities (strictures, rings, diverticula) and functional abnormalities (motility disorders, reflux) 2

Upper endoscopy is the primary diagnostic test and should be performed promptly because it allows direct visualization and biopsy of:

• Esophageal or gastric cancer 1
• Peptic strictures 1
• Erosive esophagitis 1
• Barrett esophagus 1
• Eosinophilic esophagitis (requires multiple biopsies showing >15 eosinophils per high-power field) 1
• Mucosal bridges or proximal pouches 1

For patients with suspected aspiration risk or neurologic causes, perform videofluoroscopy (VFSS) or fiber optic endoscopic evaluation of swallowing (FEES) to assess swallowing mechanics, bolus manipulation, pharyngeal constriction, and aspiration 4. This is critical because 55% of patients with aspiration have silent aspiration without protective cough reflex, making clinical examination alone insufficient 2, 4

Critical Pitfall to Avoid

Do not assume dysphagia is simply "refractory GERD" without investigation. The presence of dysphagia fundamentally changes the clinical picture from uncomplicated GERD to a condition requiring urgent evaluation for serious complications 1. Older adults have higher rates of silent aspiration than younger patients, reducing reliability of bedside evaluations 2

Initial Management While Awaiting Evaluation

Keep the patient NPO (nothing by mouth) immediately if aspiration risk is suspected, particularly in elderly patients or those with cardiac comorbidities. 4

If GERD is confirmed and no mechanical obstruction is found:

• Initiate empirical acid suppression with proton-pump inhibitors (PPIs) once daily, taken 30-60 minutes before meals 1, 5, 6
• Escalate to twice-daily PPI therapy if once-daily is unsuccessful 1
• If 4-8 weeks of twice-daily empirical PPI therapy is unsuccessful, endoscopy is mandatory 1
• Any PPI (omeprazole 20-40 mg, lansoprazole 15-30 mg, esomeprazole, pantoprazole, rabeprazole) may be used as absolute differences in efficacy are small 1, 5, 6

For patients with documented severe erosive esophagitis (grade B or worse), perform follow-up endoscopy after 8 weeks of PPI therapy to ensure healing and rule out Barrett esophagus, as incomplete healing is common and Barrett mucosa may develop in areas of previously denuded epithelium 1

Specific Considerations for GERD-Related Dysphagia

Peptic strictures require endoscopic dilation and long-term PPI therapy. Recurrence of strictures is common, and repeated endoscopy with dilation may be required 1. However, in patients with a history of stricture who remain asymptomatic, routine endoscopy is not necessary 1

Barrett esophagus carries a 0.5% annual risk of progression to adenocarcinoma, but the presence of high-grade dysplasia increases cancer risk to over 25% 1. Patients found to have Barrett esophagus should undergo endoscopic surveillance at 3-5 year intervals if no dysplasia is present 1

When Swallowing Dysfunction is Confirmed

Implement compensatory strategies immediately:

• Postural techniques (chin-down posture during swallowing) 4
• Dietary modifications using thickened liquids for patients aspirating on thin liquids, though monitor fluid intake closely as thickened liquids fail to substantially increase fluid intake and carry high risk of insufficient oral intake 1, 4
• Texture-modified diets only after clinical swallow exam and/or instrumental assessment (VFSS or FEES) 1

Provide restorative swallowing therapy including exercises for lingual resistance, breath-holding, effortful swallowing, and the Shaker exercise (repetitive head lifts in supine position), which has shown significant improvement in upper esophageal sphincter opening 4

Consult a dietitian immediately to prevent malnutrition and consider enteral nutrition for patients with unsafe oral intake or severe weight loss 4. However, in patients with severe comorbidities, mortality associated with tube feeding is significant (35-63% at 6 months, 52-84% at 1 year) 4