From the Guidelines
For a 76-year-old man with chronic dysphagia that is worsening, accompanied by retrosternal chest pain, choking, postprandial cough, sensation of food sticking, and regurgitation, the best approach before proceeding to surgery would be option D: OGD (Esophagogastroduodenoscopy) with biopsy. This recommendation is based on the most recent and highest quality evidence available, specifically the British Society of Gastroenterology guidelines for oesophageal manometry and oesophageal reflux monitoring 1. The key points supporting this recommendation include:
- OGD allows for direct visualization of the esophageal lumen and mucosa, enabling the identification of structural abnormalities such as strictures, masses, or inflammatory changes that could explain the patient's symptoms.
- The biopsy component of OGD is crucial as it provides histological examination to rule out malignancy, a significant concern in elderly patients with progressive dysphagia.
- OGD can detect esophageal cancer, achalasia, peptic strictures, or eosinophilic esophagitis, all of which present with similar symptoms.
- While esophageal manometry (option C) is valuable for motility disorders, and 24-hour pH monitoring (option A) helps diagnose GERD, these tests don't provide the direct visualization and tissue sampling needed in this case.
- Esophagoscopy (option B) is similar to OGD but typically doesn't include the comprehensive evaluation of the stomach and duodenum that might be relevant to his symptoms. The American Gastroenterological Association medical position statements on the management of gastroesophageal reflux disease 1 and the clinical use of esophageal manometry 1 further support the importance of OGD in the diagnostic workup of patients with dysphagia, especially when considering surgery. Given the progressive nature of symptoms in an elderly patient, ruling out malignancy before considering surgical interventions is paramount, making OGD with biopsy the most appropriate initial step.
From the Research
Diagnostic Approach for Dysphagia
The patient's symptoms of chronic dysphagia, retrosternal chest pain, choking, postprandial cough, sensation of food sticking, and regurgitation require a thorough diagnostic evaluation. The best initial step before proceeding to surgery would involve assessing the esophagus for any structural abnormalities or motility disorders.
Recommended Diagnostic Tests
- OGD with biopsy: This is considered a crucial initial diagnostic test for evaluating esophageal dysphagia, as it allows for the assessment of the esophageal structure and the esophago-gastric junction, as well as the collection of biopsies to rule out conditions such as eosinophilic esophagitis (EoE) 2, 3.
- Esophageal manometry: If the OGD does not reveal any explanatory findings, esophageal manometry, particularly high-resolution manometry (HRM), is the next logical step to evaluate for motility disorders 3, 4.
Rationale for Choosing OGD with Biopsy
The choice of OGD with biopsy as the initial diagnostic step is supported by studies that highlight the importance of endoscopy in evaluating dysphagia, including the detection of structural abnormalities and the collection of biopsies to diagnose or exclude conditions like EoE 2, 3. While esophageal manometry is crucial for diagnosing motility disorders, it is typically recommended after an initial endoscopic evaluation, especially if the endoscopy findings do not explain the patient's symptoms 4.
Considerations for Surgical Intervention
Before proceeding to surgery, it is essential to have a comprehensive understanding of the patient's condition through diagnostic tests like OGD with biopsy and esophageal manometry. Surgical guidelines for older adults emphasize the importance of multidisciplinary care and thorough preoperative evaluation 5. However, the provided evidence does not directly address the surgical management of dysphagia in older adults but highlights the importance of diagnostic evaluation before considering surgical options.