What is the differential diagnosis for an adult patient with a history of gastrointestinal issues presenting with dysphasia, sore throat, and epigastric pain after undergoing an EGD?

Differential Diagnosis for Dysphagia, Sore Throat, and Epigastric Pain Post-EGD

The most likely diagnosis is post-procedural pharyngeal and esophageal trauma from the endoscopy itself, but you must immediately exclude life-threatening complications including esophageal perforation, gastric volvulus, and infectious esophagitis, while also considering that the underlying pathology prompting the EGD may still be present. 1, 2

Immediate Life-Threatening Complications to Exclude

Post-EGD Perforation

• Check vital signs immediately for fever ≥38°C, tachycardia ≥110 bpm, or hypotension, which predict perforation or sepsis with high specificity 1
• Esophageal perforation presents with severe chest or epigastric pain, dysphagia, fever, subcutaneous emphysema, and mediastinal air on imaging 1
• Order CT chest/abdomen/pelvis with IV and oral contrast emergently if perforation is suspected—this shows extraluminal gas in 97% of cases, fluid or fat stranding in 89%, and focal wall defect in 84% 1
• Mortality reaches 30% if treatment is delayed beyond 24 hours 1

Gastric Volvulus Post-EGD

• Gastric volvulus is a rare but documented complication of diagnostic EGD presenting with severe epigastric pain, vomiting, and abdominal distension immediately after the procedure 2
• The classic triad includes severe epigastric pain, retching without productive vomiting, and inability to pass a nasogastric tube 2
• Emergency laparotomy is required for gastric decompression, untwisting, and gastropexy 2

Cardiac Causes

• Obtain an ECG within 10 minutes and measure serial cardiac troponins at 0 and 6 hours, as myocardial infarction can present with epigastric pain and carries 10-20% mortality if missed 1, 3, 4
• This is critical especially in women, diabetics, elderly patients, and those with cardiovascular risk factors 1, 4

Post-Procedural Complications (Most Common)

Mechanical Pharyngeal/Esophageal Trauma

• Sore throat and dysphagia occurring immediately after EGD are typically benign self-limited complications from mechanical trauma during scope insertion 5
• These symptoms usually resolve within 24-48 hours without intervention 5
• However, if symptoms worsen or persist beyond 48 hours, or if fever develops, perforation must be excluded 1

Post-Procedural Esophagitis

• Mucosal injury from the endoscope can cause transient esophagitis with dysphagia and epigastric pain 5
• Initiate high-dose PPI therapy (omeprazole 40 mg once daily) for symptomatic relief 1, 3

Underlying Pathology That May Have Prompted the EGD

Eosinophilic Esophagitis (EoE)

• EoE presents with dysphagia (29-100% of adults), epigastric pain, and food bolus obstruction, and is strongly associated with atopy 5
• Review the EGD findings for rings, furrows, exudates, strictures, or mucosal granularity—these are seen in 93% of EoE patients 5
• Check the biopsy results for ≥15 eosinophils per high-power field, which confirms the diagnosis 5
• EoE can have a macroscopically normal esophagus in 21% of cases, making biopsy essential 5

Infectious Esophagitis

• Herpes simplex virus (HSV) esophagitis presents with severe odynophagia, dysphagia, and epigastric pain, and can occur in immunocompetent hosts 6
• EGD shows ulcerated mucosa, exudative debris, hemorrhage, and multiple erosions 6
• Biopsy demonstrates multinucleated giant cells and nuclear molding consistent with HSV 6
• Treatment with oral acyclovir leads to complete symptom resolution 6
• Candida esophagitis is less likely in immunocompetent patients but should be considered if white plaques were seen on EGD 5

Gastroesophageal Reflux Disease (GERD) and Esophagitis

• GERD affects 42% of Americans monthly and presents with epigastric pain, heartburn, and regurgitation 5, 1
• Approximately 66% of GERD patients experience both heartburn and epigastric pain 1
• Esophagitis appears as fine nodularity, erosions, ulcers, thickened folds, or strictures on EGD 1
• Continue or initiate PPI therapy at 20-40 mg once daily for 4-8 weeks 3, 4

Peptic Ulcer Disease (PUD)

• PUD has an incidence of 0.1-0.3% but complications occur in 2-10% of cases, with perforation carrying 30% mortality 5, 1
• Presents with epigastric pain not relieved by antacids, and can cause hematemesis 1
• Review EGD findings for gastric or duodenal ulcers, and check biopsy results for Helicobacter pylori 5
• If H. pylori is positive, initiate eradication therapy to eliminate ulcer mortality risk 3

Gastritis

• Gastritis presents with epigastric pain and appears as enlarged areae gastricae, nodules, thickened folds, or erosions on EGD 1
• Associated with NSAID use, alcohol, or H. pylori infection 1
• Test for H. pylori and treat if positive 3

Gastric Cancer

• Gastric cancer may present with dysphagia, epigastric pain, weight loss, and an ulcer with nodularity or mass effect on EGD 1
• Review biopsy results carefully for malignancy 5

Diagnostic Algorithm

1. Assess vital signs immediately—fever, tachycardia, or hypotension mandate urgent imaging 1
2. Perform physical examination for peritoneal signs, subcutaneous emphysema, and cardiac abnormalities 1, 4
3. Obtain ECG and serial troponins at 0 and 6 hours to exclude myocardial infarction 1, 3, 4
4. Order complete blood count, C-reactive protein, serum lactate, liver and renal function tests 1
5. If perforation or volvulus is suspected, obtain CT chest/abdomen/pelvis with IV and oral contrast emergently 1, 2
6. Review the EGD report and biopsy results for underlying pathology (EoE, esophagitis, PUD, gastritis, malignancy) 5
7. If symptoms are mild and vital signs are stable, initiate empiric PPI therapy (omeprazole 40 mg once daily) and observe for 24-48 hours 1, 3, 4
8. If symptoms worsen, fever develops, or symptoms persist beyond 48 hours, obtain urgent imaging and surgical consultation 1, 2

Critical Pitfalls to Avoid

• Never dismiss cardiac causes in patients with epigastric pain—always obtain ECG and troponins 1, 3, 4
• Do not attribute all post-EGD symptoms to benign trauma—perforation and volvulus are rare but life-threatening 1, 2
• Avoid delaying imaging in patients with fever, tachycardia, peritoneal signs, or worsening symptoms 1
• Do not miss EoE by failing to review biopsy results—21% of EoE patients have normal-appearing esophagus on EGD 5
• Recognize that HSV esophagitis can occur in immunocompetent hosts and may be a harbinger of EoE 6