What is the recommended diagnostic and treatment approach for a patient presenting with dysphagia possibly due to gastro‑oesophageal reflux disease (GORD)?

Diagnostic and Treatment Approach for Dysphagia in the Context of GORD

Dysphagia in a patient with suspected GORD requires immediate endoscopy with biopsies to exclude alternative diagnoses including eosinophilic oesophagitis, peptic stricture, achalasia, and malignancy before attributing symptoms to reflux disease alone. 1

Initial Diagnostic Approach

When dysphagia is present, do not rely on empiric PPI therapy alone. The presence of dysphagia fundamentally changes the diagnostic pathway and mandates direct visualization:

• Perform upper endoscopy with biopsies as the first-line investigation when dysphagia accompanies reflux symptoms 1
• Take at least 5 oesophageal biopsies even if the mucosa appears normal, specifically to evaluate for eosinophilic oesophagitis 1
• Endoscopy identifies critical non-GORD causes including peptic strictures, eosinophilic oesophagitis, achalasia, infection, pill injury, and malignancy 1

Key Differential Diagnoses to Exclude

The presence of dysphagia should trigger consideration of:

• Eosinophilic oesophagitis - particularly common in children (30% previously misdiagnosed as GORD) and strongly associated with dysphagia, food bolus obstruction, and atopy in adults 1
• Peptic stricture - a complication of chronic GORD requiring specific management 2
• Achalasia - a motility disorder that can mimic GORD symptoms 1
• Malignancy - especially with progressive dysphagia or weight loss 1

Management Algorithm Based on Endoscopic Findings

If Peptic Stricture is Identified

Initiate PPI therapy immediately and perform endoscopic dilation - this combination is non-negotiable for peptic strictures:

• Start once-daily PPI taken 30-60 minutes before meals 2
• Perform graded dilation weekly or bi-weekly until easy passage of ≥15mm dilator is achieved 2
• Continue PPI indefinitely - patients with peptic strictures should never be weaned off acid suppression, unlike uncomplicated GORD 2
• PPIs are superior to H2-receptor antagonists in reducing repeat dilation needs and stricture recurrence 2

Critical safety measure: Provide patients with emergency contact information for chest pain or breathlessness after dilation, as perforation is a recognized complication 2

If Eosinophilic Oesophagitis is Identified

• In children with persistent GORD symptoms despite PPI therapy, endoscopy with biopsies is essential as 30% may have eosinophilic oesophagitis 1
• In adults with refractory reflux symptoms, endoscopy is indicated only if dysphagia or atopy are present (OR 12 for dysphagia, OR 3 for atopy), as the prevalence is otherwise low (0.8-4%) 1
• Food bolus obstruction requires urgent endoscopy on the next available list with biopsies taken at index procedure 1

If Endoscopy is Normal

When dysphagia persists despite normal endoscopy, proceed with functional testing:

• Oesophageal manometry to localize the lower oesophageal sphincter, evaluate peristaltic function, and diagnose subtle presentations of achalasia or other major motor disorders 1
• High-resolution manometry has superior sensitivity for detecting atypical achalasia and distal oesophageal spasm 1
• Ambulatory pH-impedance monitoring (off PPI for 7 days) if manometry shows no major abnormality, to quantify acid and non-acid reflux and assess symptom correlation 1

Treatment Strategy for GORD-Related Dysphagia

Medical Management

If GORD is confirmed as the cause:

• Twice-daily PPI dosing is recommended for inadequate response to once-daily therapy, though most efficacy data comes from once-daily studies 1
• Consider adding H2-receptor antagonists or alginates to PPI therapy for persistent symptoms 1
• Baclofen as add-on therapy reduces acid exposure but is limited by side effects (somnolence, dizziness, weakness) 1

When Medical Therapy Fails

Patients with refractory symptoms despite twice-daily PPI should be considered treatment failures and require further investigation:

• Verify medication compliance and timing before escalating therapy 1
• Perform pH-impedance monitoring on PPI if previous pathological GORD was documented 1
• Perform pH-impedance monitoring off PPI if no previous demonstration of pathological GORD exists 1

Surgical Intervention

Laparoscopic fundoplication is a treatment option for objectively documented GORD failing medical therapy:

• Surgery in experienced hands shows statistically significant improvements in quality of life at 3 months and 1 year compared to medical therapy 1
• Pre-operative evaluation must include endoscopy, manometry, and pH monitoring to confirm GORD and assess suitability 1
• Magnetic sphincter augmentation is an alternative surgical option in carefully selected patients 2

Common Pitfalls to Avoid

• Never assume dysphagia is simply "severe GORD" without endoscopic evaluation - you will miss eosinophilic oesophagitis, strictures, and malignancy 1
• Do not continue empiric PPI escalation in patients with dysphagia and negative endoscopy without functional testing 1
• Never wean PPIs in patients with peptic strictures, even if symptoms resolve - this is fundamentally different from uncomplicated GORD management 2
• Recognize that 25% of PPI-refractory symptoms are due to ongoing pathological acid reflux, not non-acid reflux or functional disorders 1