Dysphagia: a cost analysis of the diagnostic approach.

OBJECTIVES: The initial diagnostic approach for dysphagia is controversial. The choices include barium swallow (BaS) versus esophagogastroduodenoscopy (EGD). The aim of this study was to determine the clinical cost of establishing a diagnosis and treating dysphagia based on initial diagnostic approach (BaS vs EGD). METHODS: Clinical outcome of patients with undiagnosed dysphagia evaluated by either internists in a primary care clinic (n = 100) or gastroenterologists (n = 120) were determined based on the initial diagnostic test: BaS versus EGD. Final diagnoses in each group were determined based on any testing performed subsequent to the initial studies. Total cost in achieving the final diagnosis for each group were determined based on 2002 Medicare reimbursement cost. RESULTS: BaS (66% and 62%) and EGD (34% and 38%) were ordered in equal prevalence by gastroenterologists and internists, respectively. Final diagnoses included: benign obstruction (37% and 36%), gastroesophageal reflux disease (GERD) (18% and 44%), achalasia (17% and 1%), nonspecific esophageal motility disorder (NSEMD) (17% and 11%), neoplasm (7% and 6%), and infectious esophagitis (4% and 2%) in subspecialty and primary care clinics, respectively. Motility disorders (NSEMD and achalasia) was diagnosed more often by gastroenterologists (40 of 120, 34%) than by internists (12 of 100, 12%) (p < 0.001). GERD was the predominant diagnosis made by internists (44 of 100, 44%) compared to gastroenterologists (22 of 120, 18%) (p < 0.001). Although the cost of diagnosing benign obstruction was less for BaS ($73 +/- 13) than EGD ($370 +/- 5, p < 0.001), subsequent therapy with dilation increased the cost for barium testing first (BaS $602 +/- 22 vs EGD $515 +/- 5, p < 0.02). Cost of diagnosis or treatment of esophageal dysmotility (achalasia/NSEMD) was significantly (p < 0.001) less using BaS as the initial test. CONCLUSIONS: 1) BaS is less costly than EGD for diagnoses and treatment involving abnormal motility. 2) Initial EGD with therapeutic intent is less costly for patients with history suggesting benign obstruction. 3) Primary care physicians identified GERD and benign obstructions as the cause of dysphagia more often in their patient group than the gastroenterologists, making EGD a reasonable initial test in this setting instead of currently practiced BaS.

Eosinophilic esophagitis in adults: an emerging problem with unique esophageal features.

BACKGROUND: Eosinophilic esophagitis is an inflammatory condition in which there is dense eosinophilic infiltration of the surface lining of the esophagus. Reports of eosinophilic esophagitis pertain almost exclusively to pediatric populations. However, eosinophilic esophagitis is emerging as a clinical affliction of adults. This report describes the clinical and endoscopic findings of eosinophilic esophagitis in the largest cohort of adult patients reported to date. METHODS: Twenty-nine patients (21 men, 8 women; mean age 35 years) with documented eosinophilic esophagitis (>/=15 eosinophils per high-power field in biopsy specimens) and a significant history of chronic dysphagia for solid food (24 patients) were evaluated clinically and endoscopically during a 3-year period (1999-2002). Fourteen patients (48%) had a history of asthma, environmental allergy, or atopy. In a subset of 15 patients, the diagnostic accuracy of endoscopy was compared with that of barium contrast esophagography. RESULTS: Twenty-seven patients (93%) had abnormal endoscopic findings; 25 (86%) had unique esophageal structural changes, associated with a preserved mucosal surface, that were highly atypical for acid reflux injury. Structural alterations seen in adult patients with eosinophilic esophagitis may occur in combination or as a primary characteristic, e.g., uniform small-caliber esophagus, single or multiple corrugations (rings), proximal esophageal stenosis, or 1 to 2 mm whitish vesicles scattered over the mucosal surface. Barium contrast radiography combined with swallow of a barium-coated marshmallow identified 10 (67%) of the primary features observed endoscopically in 15 patients. However, radiography failed to detect other features noted at endoscopy (e.g., only 3/6 patients with proximal stenosis, 5/9 patients with concentric rings and none of 4 patients with small caliber esophagus). Eight of the 29 patients (20%) had a history of chronic heartburn. Twelve patients had been treated with a proton pump inhibitor and only 3 reported some improvement in the severity of dysphagia. CONCLUSIONS: Relatively young age, a history of chronic dysphagia for solid food, and endoscopic detection of unique structural alterations atypical for GERD in an adult patient should prompt a suspicion of EE and subsequent biopsy confirmation. Acid reflux appears to have a secondary role in eosinophilic esophagitis. In an uncontrolled comparison, endoscopy was superior to barium contrast radiography for the diagnosis of eosinophilic esophagitis. The incidence of eosinophilic esophagitis in adults appears to be increasing.