Management of Dysphagia with Normal OGD and HRM

Diagnostic Approach

The British Society of Gastroenterology guidelines recommend a barium swallow with solid food challenge to identify subtle structural abnormalities or functional disorders in patients with dysphagia and normal endoscopy and HRM, as solid food challenges can identify additional diagnoses that water swallows miss 1, 2
Normal HRM with water swallows does not exclude clinically significant dysphagia, as 30-70% of patients with dysmotility and dysphagia may only demonstrate abnormalities during solid food testing 1, 2
The patient should undergo a standard meal (e.g., standard quantity of cooked rice) during fluoroscopic evaluation to assess for dysphagia 1, 2

Eosinophilic oesophagitis must be excluded in patients with dysphagia, and OGD with biopsies at two levels in the oesophagus should be performed even when endoscopy appears visually normal 1, 2
Barium swallow (esophagram) can diagnose stricturing lesions that may be missed on endoscopy, particularly subtle rings, webs, or extrinsic compression 1, 2

If the patient's symptoms suggest oropharyngeal dysphagia, refer to a speech-language pathologist for clinical swallowing evaluation, and consider instrumental assessment with videofluoroscopic swallowing study (VFSS) or fiberoptic endoscopic evaluation of swallowing (FEES) 3
The distinction between oropharyngeal and esophageal dysphagia should be made through targeted history: difficulty with solids only progressing to liquids suggests mechanical obstruction, while difficulty with both solids and liquids from onset suggests motility disorder 3

Do not dismiss the patient's symptoms simply because initial testing is normal, as minor disorders of peristalsis identified on standard HRM have uncertain clinical significance 1, 2
Age 54 years places this patient at moderate risk for esophageal malignancy, particularly if there is progressive dysphagia or weight loss, and alarm features should be thoroughly assessed 3

If solid food barium swallow and repeat endoscopy with biopsies remain normal, consider functional esophageal disorder or hypersensitivity, though this is a diagnosis of exclusion 1, 2
Multidisciplinary evaluation including gastroenterology, speech-language pathology, and potentially psychology may be warranted if no structural or motility abnormality is identified after comprehensive testing 3