Who should perform an endoscopy on a patient with sudden onset of painful swallowing?

Who Should Perform Endoscopy for Sudden Onset Painful Swallowing

A gastroenterologist should perform emergent flexible endoscopy within 2-6 hours for patients with sudden onset painful swallowing (odynophagia), as this presentation requires urgent evaluation for foreign body impaction, esophageal perforation, or infectious esophagitis—conditions that carry mortality rates up to 22-50% without timely intervention. 1, 2

Timing and Urgency of Endoscopy

Emergent endoscopy (within 2-6 hours) is mandatory when:

• Complete esophageal obstruction is present with inability to swallow saliva or drooling, as aspiration and perforation risk reaches 35% 1
• Sharp foreign body ingestion is suspected (fish bones, chicken bones, metal fragments) due to high perforation risk 1, 2
• Battery ingestion has occurred, which causes pressure necrosis, electrical burns, and chemical injury 1
• Food bolus impaction with complete obstruction prevents handling of secretions 1

Urgent endoscopy (within 24 hours) is required when:

• Persistent odynophagia or dysphagia continues even with negative radiographic examination 1
• Esophageal foreign bodies without complete obstruction are present 1
• Food bolus impaction without complete obstruction causes ongoing symptoms 1

Critical Pre-Endoscopy Workup

Before endoscopy, obtain:

• Plain radiographs (neck, chest, abdomen) first, but recognize their false-negative rate reaches 47% for foreign bodies and 85% for fish or chicken bones 1
• CT scan is mandatory if perforation is suspected or plain films are negative with high clinical suspicion, as CT sensitivity is 90-100% compared to only 32% for plain X-ray 1, 2
• Never order contrast swallow studies—they increase aspiration risk in complete obstruction, coat the esophageal mucosa, and delay interventions 1, 2

Specialist Performing the Procedure

Gastroenterologists are the primary specialists performing diagnostic and therapeutic endoscopy for odynophagia because:

• They have expertise in flexible endoscopy with ability to obtain tissue specimens (histology, cytology, immunostaining, culture) for infectious esophagitis diagnosis 3
• Endoscopy allows direct visualization of injury sites and alters surgical management in 69% of trauma cases 3
• Gastroenterologists can perform therapeutic interventions during the same procedure, including foreign body removal, dilation, and stent placement 3, 2

In immunocompromised patients with odynophagia:

• Most gastroenterologists prefer endoscopy for those with severe symptoms at presentation or persistent symptoms despite empiric antifungal therapy 3
• Endoscopic appearance alone cannot accurately predict diseases other than Candida esophagitis—specimen acquisition is required for laboratory diagnosis 3

Role of Other Specialists

Speech-language pathologists (SLPs) evaluate oropharyngeal dysphagia but are not appropriate for acute odynophagia evaluation, as this typically represents esophageal pathology requiring endoscopy or barium swallow by gastroenterology 3

ENT surgeons may perform:

• Fiberoptic endoscopic evaluation of swallowing (FEES) for oropharyngeal assessment, which has low complication rates (0.1% anterior epistaxis, 0.02% posterior epistaxis, 0.08% vasovagal crises, 0.04% laryngospasm) 4
• Triple endoscopy (esophagoscopy, laryngoscopy, bronchoscopy) in trauma cases when injury to one structure raises suspicion of adjacent organ damage 3

Surgeons must be consulted immediately when:

• Suspected or confirmed perforation with extensive pleural or mediastinal contamination exists 1, 2
• Foreign body is irretrievable at endoscopy 1
• Foreign body is located close to vital structures like the aortic arch 1
• Hemodynamic instability or systemic signs of severe sepsis develop 1, 2

Critical Pitfalls to Avoid

Never rely on negative plain radiographs to exclude foreign body ingestion when history and symptoms are suggestive—proceed to CT scan instead 1, 5

Do not delay endoscopy beyond 24 hours in patients with persistent symptoms, as delayed management significantly increases morbidity and mortality from potential perforation 1, 2

Perform endoscopic evaluation even with negative imaging if persistent esophageal symptoms are present, as up to 25% of patients have underlying esophageal disorders (stricture, eosinophilic esophagitis) predisposing to impaction 1

Use low-flow CO2 insufflation rather than air during endoscopy to minimize mediastinal contamination if perforation occurs 3, 2

Endoscopy Technique Considerations

During the procedure:

• Obtain diagnostic biopsies to evaluate for underlying esophageal pathology (stricture, eosinophilic esophagitis, malignancy) 2
• Consider endoscopic band ligation as an immediate closure technique for acute contained perforations 2
• If rigid endoscopy is needed after flexible endoscopy fails, consider this as second-line approach, particularly for upper esophageal foreign bodies 2

Post-procedure monitoring:

• Monitor patients for at least 2 hours in recovery with clear written instructions on fluids, diet, and medications 3
• Suspect perforation when patients develop pain, breathlessness, fever, or tachycardia—persistent chest pain should prompt CT scan with oral contrast 3
• Provide contact information for on-call team should patients experience chest pain, breathlessness, or become unwell 3