EGD Findings That Do No Not Explain Dysphagia Are Associated With Underutilization of High Resolution Manometry

Introduction: In patients with dysphagia that is not explained by upper endoscopy, high-resolution esophageal manometry (HRM) is the next logical step in diagnostic testing. This study investigated predictors of failure to refer for HRM after an upper endoscopy that was performed for but did not explain dysphagia. Methods: This was a retrospective cohort study of patients over 18 who underwent esophagogastroduodenoscopy (EGD) for dysphagia from 2015 to 2021. Patients with EGD findings that explained dysphagia (e.g., esophageal mass, eosinophilic esophagitis, Schatzki ring, etc) were excluded from the main analyses. The primary outcome was failure to refer for HRM within one year of the index non-diagnostic EGD. We also investigated delayed referral for HRM, defined as HRM performed after the median. Multivariable logistic regression modeling was used to identify risk factors which independently predicted failure to refer for HRM, conditioned on the providing endoscopist. Results: Among 2,132 patients who underwent EGD for dysphagia, 1,240 (58.2%) did not have findings to explain dysphagia on the index EGD. Of these 1,240 patients, 148 (11.9%) underwent HRM within one year of index EGD. Endoscopic findings that did not explain dysphagia (e.g., hiatal hernia, tortuous esophagus, Barrett’s esophagus, altered anatomy) were independently associated with failure to refer for HRM (aOR 0.45, 95% CI 0.25 – 0.80). Demographic factors including race/ethnicity, insurance type, and income were not associated with failure to refer for HRM or delayed HRM. Of HRMs performed, 42.6% showed a major motility disorder and 6.8% showed a minor motility disorder. The diagnosis of a major motility disorder found on HRM was similar among those who had incidental EGD findings that were non-diagnostic for dysphagia compared to those who had completely normal EGD findings (42.4% vs 42.6%, P = 0.27) (Figure 1, Table 1). Conclusion: Findings unrelated to dysphagia appear to deter providers from referring for HRM despite its high yield.Figure 1.: A. Results of all patients HRM (n = 148) for dysphagia subtyped into Normal, Major Motility Disorders, Minor Motility Disorders and Technically Limited HRM studies. B. Patients with Major Motility Disorders (n = 63) classified by HRM results using the Chicago criteria. Table 1. - Risk Factors for Failure to Perform HRM Within One-Year Among Those Who Had a Non-diagnostic EGD that Was Performed for Dysphagia Variable HRM performed (n = 148) No-HRM performed (n = 1065) P-value Age 0.61 18–40 years old 22 (14.9%) 183 (17.2%) 40–60 years old 48 (32.4%) 345 (32.4%) 60–80 years old 67 (45.3%) 433 (40.7%) > 80 years old 11 (7.4%) 104 (9.7%) Sex 0.36 Male 46 (31.1%) 372 (34.9%) Female 102 (68.9%) 693 (65.1%) Race/Ethnicity 0.11 White 53 (35.8%) 477 (44.8%) Black 20 (13.5%) 150 (14.q%) Hispanic 47 (31.8%) 258 (24.2%) Asian 7 (4.7%) 31 (2.9%) Other / Unknown 21 (14.2%) 149 (14%) Primary Language 0.27 English 88 (59.5%) 655 (61.5%) Spanish 24 (16.2%) 131 (12.3%) Other 32 (21.6%) 265 (24.9%) Unknown 4 (2.7%) 14 (1.3%) BMI (kg/m2) 0.73 < 18% 5 (3.7%) 22 (2.3%) 18–25% 38 (28.4%) 291 (29.9%) 25–30% 30 (22.4%) 232 (23.9%) > 30% 61 (45.5%) 427 (43.9%) Insurance Status 0.67 Commercial Insurance 75 (62.5%) 575 (64.8%) Medicare (without supplemental) 11 (9.2%) 51 (5.7%) Managed Medicaid 33 (27.5%) 250 (28.2%) Medicaid 1 (0.7%) 5 (0.6%) Other 0 7 (0.8%) Marital Status 0.37 Married 75 (51.4%) 496 (47.4%) Unmarried 71 (48.6%) 551 (52.6%) Median Household income of Residential Zip Code (%) 0.31 < $42,754 48 (32.7%) 270 (25.5%) $42,754–$57,026.50 34 (23.1%) 261 (24.7%) $57,026.50–$93,248 32 (21.8%) 273 (25.8%) > $93,248 33 (22.5%) 254 (24%) Location 0.46 Outpatient 128 (86.5%) 895 (84.1%) Inpatient 20 (13.5%) 169 (15.9%) Fellow Participation in EGD 0.02 Fellow Present 58 (39.2%) 317 (29.8%) Fellow Not Present 90 (60.8%) 748 (70.2%) EGD Findings 0.02 No Findings 122 (82.4%) 747 (70.1%) Altered Anatomy 9 (6.1%) 103 (9.7%) Barrett’s Esophagus 1 (0.7%) 27 (2.5%) Hiatal Hernia 11 (7.4%) 166 (15.6%) Tortuous Esophagus 4 (2.7%) 19 (1.8%) Esophageal Varices 1 (0.7%) 3 (0.3%) Esophagram < 0.01 Not Performed 75 (50.7%) 720 (67.6%) Performed 73 (49.3%) 345 (32.4%)