What Causes Difficulty Swallowing (Dysphagia)?

Difficulty swallowing — dysphagia — is the sense of effort felt as food or drink passes from the mouth to the stomach. Some people have trouble starting the swallow; others feel the mouthful catch in the throat or the chest.

Difficulty swallowing is not a disease in itself. It can be the symptom of anything from a simple cause to a serious disease of the oesophagus. The cause should be looked into, particularly when the difficulty is new, recurrent or steadily increasing.

How does difficulty swallowing feel?

Patients describe the complaint in different ways:

• “The mouthful catches in my throat.”
• “Food will not go down my chest.”
• “I have to swallow several times to get it down.”
• “I cannot get solid food down without drinking water.”
• “I cough or feel as if I am choking while I eat.”
• “What I have eaten comes back up into my mouth.”

Each of these descriptions gives a different clue about where the difficulty is coming from.

Where does difficulty swallowing come from?

Dysphagia is generally considered in two groups.

Difficulty arising in the mouth and throat

This is called oropharyngeal dysphagia.

The patient usually has trouble starting the swallow. Coughing, a sense of choking, or food going up into the nose can occur during a meal.

Certain neurological diseases, muscle diseases and structural problems in the mouth and throat can cause this type of difficulty.

Difficulty arising in the oesophagus

This is called oesophageal dysphagia.

The patient can start the swallow but feels the mouthful catch low in the throat or behind the breastbone.

In this situation there may be a narrowing in the oesophagus, or a disorder of the way the oesophagus moves.

Why does the difference between solids and liquids matter?

One of the most important questions your doctor will ask is this:

“Do you have trouble swallowing solids, liquids, or both?”

Difficulty with solid food in particular, at the outset, calls for investigation of something causing a narrowing in the oesophagus.

Difficulty with solids and liquids together can be seen in disorders of oesophageal movement. Achalasia is one important example.

But no diagnosis can be made on these features alone.

What causes difficulty swallowing?

The causes of oesophageal dysphagia include:

• Oesophageal narrowing due to reflux
• Oesophageal rings and webs
• Eosinophilic oesophagitis
• Achalasia
• Other oesophageal motility disorders
• Structures pressing on the oesophagus from outside
• Tumours of the oesophagus

For this reason it is not right for dysphagia — particularly new or progressive dysphagia — to be left unassessed for a long period on the assumption that “it is the reflux”.

Is pain on swallowing the same thing?

No.

Dysphagia is difficulty or a sense of obstruction as food passes during the swallow.

Odynophagia is swallowing that is painful.

The two can occur together but they are different symptoms. Pain on swallowing can be seen in inflammation of the oesophagus, infection, medication-related injury and other conditions.

When should a doctor be seen without delay?

Difficulty swallowing should be taken seriously particularly in the following situations:

• The complaint is steadily increasing
• Solids stop going down first, then liquids
• Unintentional weight loss
• Anaemia
• Recurrent vomiting
• Pain on swallowing
• Signs of bleeding
• Frequent coughing or choking during meals
• Difficulty swallowing that begins for the first time at an older age

If a mouthful is completely stuck in the oesophagus and the person cannot even swallow their own saliva, emergency assessment is needed.

How is the diagnosis made?

One of the first and most important stages of the diagnosis is listening to the patient’s complaint in detail.

Depending on the features of the difficulty, your doctor may request one or more of the following:

Upper gastrointestinal endoscopy

This allows the oesophagus to be seen directly. Narrowings, inflammatory changes, tumours and other structural problems can be investigated.

Where it is thought necessary, a biopsy can be taken during the same procedure.

Barium swallow

The shape of the oesophagus and the passage through it are assessed while the patient swallows a contrast medium. It can be useful in demonstrating some narrowings and motility disorders.

Oesophageal manometry

This measures the contractions of the oesophagus and how the lower oesophageal sphincter works.

It matters particularly in diagnosing achalasia and other oesophageal motility disorders.

Some patients need further imaging or function tests in addition to these.

Is there a treatment for difficulty swallowing?

Treatment depends on the cause of the dysphagia.

Some narrowings in the oesophagus can be dilated endoscopically, for example. In disease due to reflux, appropriate medical treatment can be given. Eosinophilic oesophagitis has treatments of its own. In achalasia and other motility disorders, endoscopic, surgical or other methods can be used depending on the type of disease.

There is therefore no “single treatment for difficulty swallowing”; the cause has to be established first.

Take difficulty swallowing seriously

Occasionally struggling to get a mouthful down while eating quickly is not the same thing as recurrent or steadily increasing dysphagia.

Gastroenterology assessment should not be delayed, particularly where the difficulty is new, is increasing, is accompanied by weight loss, or is most obvious with solid food.

Remember: difficulty swallowing is not a diagnosis. It is a symptom whose underlying cause needs to be investigated. Information on the internet should not be used to reach your own diagnosis. A correct diagnosis requires the patient’s history, their examination and whatever endoscopic or other investigations are thought necessary, assessed together.