What is the best course of action for a 64-year-old female with a one-week history of dysphagia (difficulty swallowing) characterized by burning discomfort, weight loss, and fear of eating, who has been taking omeprazole (proton pump inhibitor) without improvement, has a history of smoking one pack of cigarettes daily, and reports chronic right upper back pain?

Urgent Upper Endoscopy is Indicated for This Patient

This 64-year-old woman with burning dysphagia, significant weight loss, failure of PPI therapy, and heavy smoking history requires urgent upper endoscopy (esophagogastroduodenoscopy) to rule out esophageal malignancy. 1, 2

Why Endoscopy Cannot Be Delayed

Alarm Features Present

• Dysphagia with weight loss (2 pounds in one week, now 94 pounds) represents a critical alarm symptom requiring immediate endoscopic evaluation. 1, 2
• The American College of Physicians explicitly states that upper endoscopy is indicated in patients with heartburn and alarm symptoms including dysphagia, weight loss, and symptoms persisting despite PPI therapy. 1
• Failure of 4-8 weeks of PPI therapy (she's been taking omeprazole without improvement) is a specific indication for upper endoscopy. 1
• Fear of eating and progressive weight loss indicate severe nutritional compromise that raises strong suspicion for mechanical obstruction or malignancy. 2

High-Risk Patient Profile

• Age 64 years with chronic smoking (one pack daily) places her in the highest risk category for esophageal adenocarcinoma. 1, 2
• The American College of Physicians recommends screening endoscopy in patients older than 50 years with chronic GERD symptoms and additional risk factors including tobacco use. 1
• The burning sensation as food passes suggests esophageal pathology, not simple oropharyngeal dysphagia. 3, 4

Critical Timing Considerations

• Do not continue empiric PPI therapy when alarm symptoms are present—this delays cancer diagnosis when early detection is critical. 2
• Endoscopy should be performed while symptoms are present to maximize diagnostic yield. 2
• Waiting for further weight loss or bleeding represents advanced disease; dysphagia with weight loss alone warrants immediate investigation. 2

What the Endoscopy Will Accomplish

Diagnostic Priorities

• Rule out esophageal or gastric malignancy as the primary concern. 1, 2
• Identify peptic strictures, erosive esophagitis, or Barrett's esophagus that may explain symptoms. 1
• Obtain multiple four-quadrant biopsies at 2 cm intervals if any mucosal abnormality is detected, as this increases diagnostic accuracy to nearly 100%. 2
• Evaluate for eosinophilic esophagitis, which requires esophageal biopsies for diagnosis. 3

Therapeutic Potential

• If stricture is identified, endoscopic dilation can be performed during the same procedure. 1
• If severe erosive esophagitis is found, follow-up endoscopy after 2 months of PPI therapy will assess healing and rule out Barrett's esophagus. 1

Concurrent Nutritional Assessment is Critical

Immediate Nutritional Intervention

• Weight of 94 pounds with ongoing weight loss represents severe nutritional risk requiring urgent dietitian consultation. 2
• The ESPEN guidelines specify that unintentional weight loss >5% in 3 months or BMI <20 kg/m² indicates nutritional risk requiring intervention. 2
• Consider enteral nutrition support (nasogastric or PEG tube) if oral intake remains unsafe or inadequate after diagnostic workup. 2

Aspiration Risk Assessment

• While she denies choking episodes, silent aspiration occurs in up to 55% of patients with dysphagia without protective cough reflex. 2
• Monitor for signs of aspiration pneumonia (fever, cough, respiratory symptoms) given her smoking history and dysphagia. 2

The Chest X-Ray is Appropriate But Secondary

Rationale for Chest Imaging

• Chest X-ray is reasonable given chronic right upper back pain and smoking history to evaluate for pulmonary pathology. 2
• However, chest X-ray does not evaluate the esophagus adequately—endoscopy remains the primary diagnostic modality. 1, 2

Alternative Imaging if Endoscopy Delayed

• If immediate endoscopy is not available, videofluoroscopic esophagram (barium swallow) has 96% sensitivity for esophageal cancer and can identify mechanical obstruction. 2
• Fluoroscopy remains the imaging modality of choice for dysphagia evaluation when endoscopy is not immediately accessible. 1, 2

Pain Management Considerations

Addressing Chronic Pain

• Referral to pain management specialist is appropriate for chronic right upper back pain. 2
• However, do not allow pain management to distract from the urgent need to evaluate her dysphagia and weight loss. 2
• Opioid medications, if prescribed for pain, can cause esophageal dysmotility and worsen dysphagia. 3

Common Pitfalls to Avoid

• Do not empirically treat as simple GERD or continue PPI therapy when alarm symptoms are present—she has already failed omeprazole. 1, 2
• Do not perform barium studies as the initial test when endoscopy is available—endoscopy allows both diagnosis and biopsy. 1, 2
• Do not delay endoscopy while arranging other consultations (pain management, dietitian)—these can occur concurrently. 2
• Do not assume her ability to tolerate ramen noodles means the dysphagia is mild—selective tolerance of soft foods is classic for esophageal obstruction. 3, 4
• Do not rely on her denial of food getting stuck to rule out mechanical obstruction—burning sensation with passage of food is still concerning for esophageal pathology. 3, 4

Multidisciplinary Team Assembly

Immediate Referrals Needed

• Gastroenterology for urgent upper endoscopy (within 2 weeks maximum, ideally sooner given weight loss). 1, 2
• Registered dietitian for nutritional assessment and intervention planning. 2
• Speech-language pathologist consultation if oropharyngeal component is suspected after endoscopy. 1
• Oncology consultation if malignancy is identified. 2

Smoking Cessation

• Initiate smoking cessation counseling immediately—continued smoking worsens both cancer risk and healing of any esophageal pathology. 1
• Her inability to tolerate beer due to discomfort may actually facilitate smoking cessation efforts. 1