Difficulty Swallowing

Differential Diagnosis

Common Diagnoses

Occasional Diagnoses

  • Pharyngeal Pouch
  • Pharyngeal Carcinoma
  • Compression by Mediastinal Tumours (e.g. Lymphoma, Bronchial Carcinoma)
  • Oesophageal Achalasia
  • Gastric Carcinom
  • 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.

Published: 2nd August 2022 Updated: 10th April 2024

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