What are the diagnostic and treatment steps for a patient with epigastric pain upon swallowing, potentially with a history of gastrointestinal issues or NSAID use?

Epigastric Pain with Swallowing

For a patient presenting with epigastric pain upon swallowing, immediately pursue upper endoscopy if alarm features are present (age ≥55 years, weight loss, dysphagia, anemia, or persistent vomiting), as this represents the gold standard for diagnosing esophagitis, peptic ulcer disease, or malignancy. 1

Immediate Clinical Assessment

Distinguish between oropharyngeal versus esophageal dysphagia through targeted history:

• Dysphagia for solids that progresses to liquids suggests mechanical obstruction (stricture, tumor), whereas simultaneous difficulty with both solids and liquids from onset indicates a motor disorder like achalasia 2
• Ask specifically about the sensation of food sticking at a particular level, which mandates urgent endoscopy 1
• Inquire about associated symptoms: heartburn, regurgitation, weight loss, hematemesis, or persistent vomiting 1

Check for alarm features that require urgent intervention:

• Weight loss (requires objective documentation) 1
• Anemia on complete blood count 1
• Dysphagia or food sticking sensation 1
• Persistent vomiting (excludes functional disease and suggests serious organic pathology) 1
• Age ≥55 years with new or treatment-resistant symptoms 1

Diagnostic Workup Algorithm

First-Line Imaging Studies

Order a biphasic barium esophagram (combined double-contrast and single-contrast technique) for optimal sensitivity (88%) in detecting esophagitis and structural abnormalities:

• Double-contrast phase with high-density barium detects inflammatory or neoplastic diseases 2
• Single-contrast phase with low-density barium optimally identifies hiatal hernias, lower esophageal rings, or strictures 2
• This combined technique reveals fine nodularity or granularity of mucosa, erosions, ulcers, thickened longitudinal folds, and strictures characteristic of reflux esophagitis 2, 1

Consider CT abdomen with IV contrast if complications are suspected:

• Detects perforation (extraluminal gas in 97% of cases), fluid or fat stranding (89%), ascites (89%), focal wall defects (84%), and wall thickening (72%) 1
• Particularly useful if peptic ulcer disease complications are suspected 2

Endoscopic Evaluation

Proceed directly to upper endoscopy (bypassing empiric therapy) if any of the following apply:

• Age ≥55 years with new-onset symptoms 1
• Presence of any alarm features listed above 1
• Epigastric tenderness on physical examination (suggests organic rather than functional pathology) 1
• Symptoms persisting beyond 8 weeks despite treatment 1

Consult speech-language pathology when oropharyngeal dysphagia is suspected:

• Signs include coughing while swallowing, nasal regurgitation, wet vocal quality after swallowing, poor secretion management, or weak cough 2
• Consider videofluoroscopic swallow study (VFSS) or fiberoptic endoscopic evaluation of swallowing (FEES) for instrumental assessment 2
• Note that older adults have higher rates of silent aspiration, making clinical bedside evaluations less reliable 2

Empiric Treatment While Awaiting Diagnosis

Initiate high-dose proton pump inhibitor therapy immediately in patients without alarm features:

• Omeprazole 20-40 mg once daily before meals 1
• Achieves healing rates of 80-90% for duodenal ulcers and 70-80% for gastric ulcers 1
• This is first-line for ulcer-like dysphagia while diagnostic workup proceeds 1

For symptomatic relief of associated nausea:

• Ondansetron 8 mg sublingual every 4-6 hours (obtain baseline ECG due to QTc prolongation risk) 1
• Promethazine 12.5-25 mg orally/rectally every 4-6 hours 1
• Prochlorperazine 5-10 mg every 6-8 hours 1

Critical Pitfalls to Avoid

Never delay endoscopy in patients with alarm features, as this can lead to poor outcomes including missed gastric cancer or advanced peptic ulcer disease complications. 1

Do not attribute persistent vomiting with epigastric pain to functional dyspepsia—this combination excludes functional disease by Rome IV criteria and mandates investigation for structural pathology. 1

Avoid dismissing cardiac causes in atypical presentations:

• Obtain ECG within 10 minutes for any patient with epigastric pain, as myocardial infarction can present atypically (especially in women, diabetics, and elderly) with 10-20% mortality if missed 3, 4
• Check serial troponins at 0 and 6 hours 3, 4

Do not perform swallowing assessments on delirious patients who cannot participate, as this may be futile and delay appropriate management. 2

Consider age-related changes in swallowing physiology:

• Sarcopenia affects swallowing muscles, decreasing oral tongue force generation 2
• Xerostomia from medications and decreased salivary flow exacerbates swallowing difficulties 2
• These factors may contribute to symptoms independent of structural pathology 2