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Diagnostic approach

In many patients with dysphagia, no single test is used to make a diagnosis, as endoscopy, radiography, and manometry are often used in a complementary manner [19]. While a barium esophagram has traditionally been the initial test used to evaluate dysphagia, most patients now proceed directly to an upper endoscopy [20]. Endoscopy not only allows for detailed anatomic and mucosal evaluations but also serves as both a diagnostic and therapeutic study, as the physician can take biopsies and dilate the esophagus in the same session. A barium esophagram allows for greater evaluation of potential motility disorders, as well as anatomic abnormalities such as a large hiatal or paraesophageal hernia. As compared to endoscopy, a barium esophagram is also more sensitive for the detection of esophageal strictures [21, 22], and the use of a 13 mm barium tablet can detect subtle strictures that may not be appreciated at the time of endoscopy [23]. A pre‐endoscopy barium esophagram can also allow the physician to plan the endoscopy, as the finding of a tight stricture may determine the type of dilation required, or a diagnosis of achalasia may prompt a pneumatic dilation or the injection of botulinum toxin at the time of the procedure [18].

Figure 1.1 Algorithm for the evaluation of dysphagia.

High‐resolution esophageal manometry should be performed in patients who have an unrevealing upper endoscopy and in patients in whom a motility disorder is strongly suspected. In patients with suspected oropharyngeal dysphagia, the modified barium swallow is the test of choice, as this allows for assessment of aspiration and muscular strength and coordination, along with the opportunity to trial foods of different consistencies in an effort to replicate patient symptoms [18]. Working with a speech pathologist, a patient may also start to implement directed therapy based on the results of the study.

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