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.
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
| Globus | GORD | Stricture | Oesophageal Carcinoma | Painful Pharynx | |
|---|---|---|---|---|---|
| Weight Loss | No | No | Possible | Yes | No |
| Intermittent | Yes | Yes | No | No | No |
| Progressive | No | No | Yes | Yes | No |
| Reflux of Unchanged Food | No | No | Possible | Yes | No |
| Retrosternal Pain | No | Yes | Possible | Possible | No |
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.