Impact of referral delays on dysphagia outcomes in a Saudi tertiary center

Table 1 Baseline characteristics and clinical features of patients with dysphagia referred to King Saud Medical City (2022-2023), n (%)

Baseline characteristics	Total study population (n = 168)	Early endoscopy (< 2 weeks) (n = 36)	Delayed endoscopy (≥ 2 weeks) (n = 45)	P value
Demographics
Age (years), mean ± SD	45.7 ± 17.7	48.0 ± 17.7	44.2 ± 16.7	0.365
Male gender	82 (50.0)	19 (52.8)	18 (40.0)	0.356
Referral source
Family medicine	116 (69.4)	19 (52.8)	38 (84.4)	0.004
Emergency department	19 (11.4)	7 (19.4)	0 (0.0)	0.002
General surgery	12 (7.2)	5 (13.9)	1 (2.2)	0.083
Otorhinolaryngology	7 (4.2)	2 (5.6)	3 (6.7)	1
Oncology	6 (3.6)	1 (2.8)	0 (0.0)	0.444
Infectious diseases	2 (1.2)	1 (2.8)	0 (0.0)	0.444
Clinical features
Duration ≥ 4 weeks	57 (44.5)	18 (50.0)	22 (48.9)	1
Progressive dysphagia	64 (48.5)	15 (41.7)	19 (42.2)	1
Retrosternal location	86 (66.7)	28 (84.8)	25 (58.1)	0.024
Weight loss	54 (42.2)	14 (38.9)	20 (44.4)	0.782
Heartburn	84 (64.6)	23 (63.9)	29 (64.4)	1
Regurgitation	76 (58.0)	21 (58.3)	25 (55.6)	0.98
Chest pain	47 (35.9)	12 (33.3)	16 (35.6)	1
Globus sensation	30 (23.4)	3 (8.3)	6 (13.3)	0.724
Diagnostic workup
Manometry performed	9 (8.5)1	3 (8.3)	4 (8.9)	1
24-hour pH study	3 (2.3)1	1 (2.8)	1 (2.2)	1
Esophagogram performed	65 (38.7)	12 (33.3)	18 (40.0)	0.647
Final diagnoses
GERD	76 (45.2)	14 (38.9)	20 (44.4)	0.782
Eosinophilic esophagitis	25 (14.8)	0 (0.0)	6 (13.3)	0.031
Complicated GERD with stricture	9 (5.4)	8 (22.2)	1 (2.2)	0.009
Malignancy	11 (6.5)	1 (2.8)	0 (0.0)	0.444
Achalasia	10 (5.9)	1 (2.8)	5 (11.1)	0.219
Other diagnoses	37 (22.0)	12 (33.3)	13 (28.9)	0.809
Clinical outcomes
Improved outcome	103 (61.3)	23 (63.9)	27 (60.0)	0.898

¹Percentage of 106 patients who underwent evaluation.

GERD: Gastroesophageal reflux disease.

Table 2 Association between the time of referral of cases presented with dysphagia and the outcome of management, n (%)

	Final outcome					P value1
	The same (n = 19)	Improved (n = 103)	Worsening (n = 7)	Wrong referral (n = 4)	Died (n = 3)
Time of referral to clinical assessment by gastroenterology department in weeks (n = 133)	n = 18	n = 0	n = 0	n = 3	n = 2
≤ 2 hours (n = 72)	6 (8.3)	57 (79.2)	6 (8.3)	1 (1.4)	2 (2.8)
3-hour (n = 22)	4 (18.2)	18 (81.8)	0 (0.0)	0 (0.0)	0 (0.0)
> 4 hours (n = 39)	8 (20.5)	28 (71.8)	1 (2.6)	2 (5.1)	0 (0.0)	0.246
Time from referral to endoscopy in weeks (n = 132)	n = 18	n = 0	n = 0	n = 3	n = 1
≤ 2 hours (n = 65)	3 (4.6)	55 (84.6)	6 (9.2)	0 (0.0)	1 (1.5)
3-hour (n = 17)	6 (35.3)	10 (58.8)	0 (0.0)	1 (5.9)	0 (0.0)
> 4 hours (n = 50)	9 (18.0)	38 (76.0)	1 (2.0)	2 (4.0)	0 (0.0)	0.012
Time from referral to esophagogram in weeks (n = 60)	n = 11	n = 47	n = 0	n = 2	n = 0
≤ 2 hours (n = 30)	3 (10.0)	26 (86.7)	0 (0.0)	1 (3.3)	0 (0.0)
3-hour (n = 6)	3 (50.0)	3 (50.0)	0 (0.0)	0 (0.0)	0 (0.0)
> 4 hours (n = 24)	5 (20.8)	18 (75.0)	0 (0.0)	1 (4.2)	0 (0.0)	0.226
Time from clinical assessment to endoscopy in weeks (n = 129)	n = 18	n = 100	n = 7	n = 3	n = 1
≤ 2 hours (n = 95)	9 (9.5)	77 (81.1)	6 (6.3)	2 (2.1)	1 (1.1)
3-hour (n = 14)	6 (42.9)	6 (42.9)	1 (7.1)	1 (7.1)	0 (0.0)
> 4 hours (n = 20)	3 (15.0)	17 (85.0)	0 (0.0)	0 (0.0)	0 (0.0)	0.046
Time from clinical assessment to esophagogram in weeks (n = 50)	n = 10	n = 39	n = 0	n = 1	n = 0
≤ 2 hours (n = 29)	3 (10.3)	26 (89.7)	0 (0.0)	0 (0.0)	0 (0.0)
3-hour (n = 8)	4 (50.0)	4 (50.0)	0 (0.0)	0 (0.0)	0 (0.0)
> 4 hours (n = 13)	3 (23.1)	9 (69.2)	0 (0.0)	1 (7.7)	0 (0.0)	0.054

¹χ² test.

Total 32 cases lost to follow-up were removed from the analysis.

Table 3 Comparison of malignant and non-malignant cases of dysphagia regarding the outcome of management, n (%)

	Non-malignant cases (n = 128)	Malignant cases (n = 6)	P value1
The same (n = 19)	19 (14.8)	0 (0.0)	< 0.001
Improved (n = 101)	101 (79.0)	0 (0.0)
Worsening (n = 7)	2 (2.3)	4 (66.7)
Wrong referral (n = 4)	4 (3.1)	0 (0.0)
Died (n = 3)	1 (0.8)	2 (100)

¹χ² test.