Difficulty Swallowing

This symptom can mean several things, and a careful history is necessary to tease out the precise problem: Difficulty in initiating swallowing; a sensation of food sticking somewhere; painful swallowing; also included here is the sensation of ‘something in the throat’ even when not trying to swallow anything.

Published: 2nd August 2022 | Updated: 15th August 2022

Differential diagnosis

Common Diagnoses

  • Globus Hystericus
  • Any Painful Pharyngeal Condition, e.g. Pharyngitis
  • GORD
  • Benign Stricture
  • Oesophageal Carcinoma

Occasional Diagnoses

  • Pharyngeal Pouch
  • Pharyngeal Carcinoma
  • Compression by Mediastinal Tumours (e.g. Lymphoma, Bronchial Carcinoma)
  • Oesophageal Achalasia
  • Gastric Carcinoma
  • Xerostomia (the Elderly, Post-Parotidectomy and Sjögren’s Syndrome)
  • Foreign Body
  • Drugs: Nsaid-Associated Oesophagitis, Failure to Take Bisphosphonate Tablets Correctly

Rare Diagnoses

  • Plummer–Vinson Syndrome
  • Chagas’s Disease (South American Trypanosomal Infection)
  • Scleroderma (Crest Syndrome), Polymyositis and Dermatomyositis
  • Neurological Disorders (e.g. Myasthenia Gravis, Bulbar Palsy)
  • Motor Neurone Disease

Ready reckoner

Key distinguishing features of the most common diagnoses

GlobusGORDStrictureOesophageal CarcinomaPainful Pharynx
Weight LossNoNoPossibleYesNo
Reflux of Unchanged FoodNoNoPossibleYesNo
Retrosternal PainNoYesPossiblePossibleNo

Possible investigations

Likely: (Unless obvious globus or local pharyngeal cause) FBC, ESR/CRP, barium swallow or endoscopy.

Possible: CXR, LFT.

Small Print: Pharyngeal swab, CT scan thorax, videofluoroscopy, oesophageal motility studies.

  • FBC and ESR/CRP: May reveal evidence of malignancy or iron-deficiency anaemia.
  • LFT if malignancy suspected: Abnormality suggests hepatic spread.
  • Barium swallow useful in the frail and to safely demonstrate stricture or motility problems if no absolute dysphagia for liquids (risk of aspiration).
  • Flexible upper GI endoscopy allows visualisation and biopsy of suspicious lesions.
  • Throat swab occasionally helpful in painful pharyngeal lesions.
  • CXR if suspicion of mediastinal tumour of any cause.
  • CT scan or further imaging may be arranged by the specialist to further define mediastinal tumours.
  • Videofluoroscopy and oesophageal motility studies: Hospital-based tests which may be required, particularly if a neurological or muscular cause is suspected.

Top Tips

  • A young patient under stress who can swallow food and drink without problems but who feels there is ‘something stuck’ almost certainly has globus. Reassurance usually resolves the situation.
  • Remember to ask about medication – recent onset of painful dysphagia may be caused by severe oesophagitis secondary to drugs such as alendronate, NSAIDs and slow-release potassium supplements.
  • Take time with the history – difficulty in swallowing can mean a number of different things, and the diagnosis is much more likely to be revealed by careful questioning than by examination.

Red Flags

  • Recent onset of progressive dysphagia with weight loss in an elderly patient is caused by oesophageal carcinoma until proved otherwise.
  • A palpable hard lymph node in the left supraclavicular fossa (Troisier’s sign) is strongly associated with gastric carcinoma.
  • Beware of patients who have a long history of oesophagitis but who complain of increasing or unusual dysphagia – they may have developed a stricture, or even a carcinoma.
  • If endoscopy does not reveal a cause but the symptom continues, remember rarer causes, such as extrinsic compression on the oesophagus or a neurological problem. Consider a barium swallow, or referral to a neurologist if there are other neurological symptoms or signs.
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Website disclaimer

Pulse Reference is based on the best-selling book Symptom Sorter.

The experts behind Pulse Reference are Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse’s editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse.

This website is for clinical guidance only and cannot give definitive diagnostic information. Practitioners should work within the limits of their individual professional practice, seek guidance when necessary and refer appropriately.