This case involves an elderly female patient with a long history of acid reflux who presented with difficulty swallowing. She was referred to an ENT who ordered a barium study for dysphagia. The study showed reflux but no abnormalities and the patient was prescribed Esomeprazole. After a few months on the medication with no improvement, the ENT recommended an esophagoscopy and direct laryngoscopy, which showed no evidence of a tumor. Following the procedures, the patient continued to have nausea episodes while eating. The patient decided to see a GI who recommended an esophagogastroduodenoscopy (EGD). The test showed severe obstruction and firm narrowing at the gastroesophageal junction. A biopsy was taken at this time and revealed esophageal carcinoma stage IV.
Question(s) For Expert Witness
- 1. Should a patient be referred to GI instead of ENT if they have a long history of acid reflux and difficulty swallowing?
- 2. Should an ENT have an understanding that exams would not properly evaluate gastroesophageal juncture and in what instances should an ENT either refer to a GI or evaluate the possibility of esophageal cancer?
Expert Witness Response E-052665
Either ENT or GI is an appropriate place to begin evaluation of swallowing complaints – I can’t fault the choice of one over the other. MBS is actually a reasonable “first pass” at ruling out mass lesions of the esophagus. Acuity of further work-up such as esophagoscopy/EGD depends on nature and severity of the dysphagia, which is not well characterized above – mild sense of effortful swallowing with stable weight, no hematemesis, and no odynophagia is not nearly as concerning, for instance, as a case which included sense that foods were mechanically sticking or a case that included any of the ‘danger’ signs of weight loss, odynophagia, or hematemesis. With this in mind, it seems that work-up from MBS to ENT Esophagoscopy to GI EGD proceeded in fairly short order, all things considered – unless the patient had a very, very strong history of the ‘danger signs’ as listed above, it does not seem that things were delayed. Keep in mind, most reflux patients with mild dysphagia don’t even need EGD – again, depending on the severity of the reflux and severity of the dysphagia. Most esophageal cancers are diagnosed as advanced stage tumors.