Clinical recommendation	Evidence rating	Comments
Patients younger than 50 years who have esophageal dysphagia and no other worrisome symptoms should undergo a four-week trial of acid suppression therapy before endoscopy is performed.9,26,27	B	CAG and ACG guidelines; systematic review of seven retrospective cohort studies showing a positive predictive value of less than 1% for malignancy
Patients with apparent oropharyngeal symptoms but a negative evaluation should be referred for EGD to rule out esophageal pathology.28	C	Retrospective review of 3,668 consecutive patients; distal esophageal pathology was incorrectly perceived as arising from the neck or throat in 15% to 30% of cases
EGD is recommended for the initial assessment of patients with esophageal dysphagia; barium esophagography is recommended as an adjunct if EGD findings are negative.9,29,30	C	CAG, STS, and WGO guidelines; expert consensus based on limited evidence and cost-analysis; EGD has greater sensitivity and specificity than barium esophagography, with greater cost-effectiveness
For accurate diagnosis of eosinophilic esophagitis, biopsies from normal-appearing mucosa in the midthoracic and distal esophagus should be requested for all patients with unexplained solid food dysphagia.15,17	B	Expert consensus recommendation based on CAG, ACG, and AGA guidelines; early-stage eosinophilic esophagitis may not exhibit mucosal changes on endoscopy
Older patients with chronic illness or recent pneumonia should be screened for dysphagia; if it is present, the physician and patient should discuss goals of care.22,43	C	Expert consensus on dysphagia as a geriatric syndrome