Difficulty Swallowing (Dysphagia): Causes, Tests and When to See a Doctor Urgently

Oropharyngeal dysphagia affects the first, brain-controlled phase of swallowing. Patients describe difficulty starting a swallow, coughing or choking during or just after swallowing, food leaking through the nose, a wet or “gurgly” voice after eating and recurrent pneumonia. Typical causes are neurological diseases (stroke, Parkinson’s disease, neuromuscular disorders, dementia), lesions in the throat and larynx (tumours, effects of radiotherapy) and a pharyngo-oesophageal diverticulum.

Oesophageal dysphagia affects the later segment. The patient can usually start a swallow but after a moment feels that food is stopping behind the breastbone or in the neck. The place where it is felt does not always match the site of the obstruction, so it should not be treated as an exact indicator. The cause may be a narrowing (mechanical) or a disorder of oesophageal movement (functional).

An important clinical clue concerns consistency. Difficulty with solid foods that over time also involves liquids is typical of oesophageal motility disorders (for example achalasia). Difficulty at first only with solids, and progressive, suggests a mechanical obstruction such as a stricture or tumour. Difficulty with liquids from the start, especially with coughing, more often points to an oropharyngeal or neurological cause. These are only clues — a definite diagnosis requires tests.

Four groups matter most among the causes of oesophageal dysphagia. The first is reflux disease and its consequences: chronic oesophagitis can lead to a stricture that hinders the passage of solid food. We write about reflux and its treatment in the knowledge base. The second group is eosinophilic oesophagitis (EoE), a chronic immune disease of the oesophageal lining. The third is motility disorders, of which achalasia is the best known. The fourth is cancer of the oesophagus and of the oesophagogastric junction, which has to be excluded first, especially in older people.

Rarer but significant causes include rings and webs in the oesophagus, drug-induced oesophagitis (when a tablet gets stuck and irritates the lining), infectious oesophagitis (for example fungal) in people with weakened immunity, external compression and changes after radiotherapy. Dysphagia may also accompany systemic diseases such as scleroderma. Because the range of possibilities is wide, it is not worth guessing the cause from symptoms alone.

Eosinophilic oesophagitis (EoE) is easily overlooked because a normal-looking gastroscopy does not exclude the disease — diagnosis requires a biopsy. A review published in JAMA estimates the frequency of EoE at about 34.4 cases per 100,000 people in Europe and North America. Diagnosis rests on symptoms of oesophageal dysfunction and the presence of at least 15 eosinophils per high-power field on biopsy, with other conditions such as reflux or achalasia excluded.

The good news is that treatment is available. The 2025 American College of Gastroenterology guideline lists as recommended approaches: proton pump inhibitors, topical steroids, an empiric elimination diet, a biologic drug and oesophageal dilation, with monitoring of clinical, endoscopic and histological response. In the JAMA review, histological response to PPIs was 41.7% (versus 13.3% on placebo, observational data), and to topical corticosteroids 64.9% versus 13.3% (8 randomised trials, 437 patients). It is therefore worth knowing that taking a PPI before gastroscopy may change the biopsy picture — tell the doctor which medicines you take.

Achalasia is a disorder of oesophageal movement in which abnormal peristalsis is combined with inadequate relaxation of the lower oesophageal sphincter. According to the ACG guideline, patients most often report dysphagia to solids and liquids, regurgitation and sometimes chest pain, with or without weight loss. High-resolution manometry can distinguish three subtypes of achalasia, and diagnostic clues are retained saliva and a ‘puckered’ gastro-oesophageal junction at endoscopy and, on a contrast study, a dilated oesophagus with a ‘bird’s beak’ appearance.

Because achalasia sometimes presents like reflux (heartburn, regurgitation), it can be wrongly treated with proton pump inhibitors for years. If despite reflux treatment progressive dysphagia and regurgitation of undigested food appear, it is worth asking the doctor about further work-up. Treatment of achalasia (dilation, myotomy, endoscopic procedures) requires a specialist’s decision at an experienced centre.

Functional disorders form a separate, important group. According to the Rome IV classification, functional oesophageal disorders comprise symptoms such as heartburn, chest pain, dysphagia or globus that are not explained by mechanical lesions (stricture, tumour, EoE), major motor disorders (achalasia, outflow obstruction, absent contractility, distal oesophageal spasm, jackhammer oesophagus) or reflux disease. A functional diagnosis is made only after those causes are excluded, and the presumed mechanisms are visceral hypersensitivity and hypervigilance.

The choice of test depends on the suspected type of dysphagia. In oesophageal dysphagia the first test is usually gastroscopy (upper gastrointestinal endoscopy) with biopsies — even when the lining looks normal, so as not to miss eosinophilic oesophagitis. The role of endoscopy in evaluating and treating dysphagia (including dilating strictures) is the subject of guidance from the American Society for Gastrointestinal Endoscopy (ASGE). We describe the procedure and its preparation in the knowledge base entry on gastroscopy, and the role of biopsy in the entry on biopsy.

When gastroscopy does not explain the cause and dysphagia persists, the next steps are often a contrast study of the oesophagus and high-resolution manometry, which assesses oesophageal contractions and sphincter function. In oropharyngeal dysphagia, videofluoroscopy (an X-ray study with contrast that records swallowing) or endoscopic evaluation of swallowing is used, along with ENT and neurological consultation. In selected cases CT or MRI is needed.

The practical conclusion: dysphagia is among the strongest single alarm features, and among people referred for rapid diagnosis a substantial share have serious disease, not only cancer — also ulcer or stricture. This does not mean every dysphagia is cancer (in this population cancer affected about 4%), but that work-up should not be postponed.

Equally wrong is the belief that dysphagia in older people is a “normal sign of age” and needs no tests. Swallowing disorders become more frequent with age, but that is not the norm — it is a signal to look for the cause, because oropharyngeal dysphagia carries a risk of aspiration and malnutrition and oesophageal dysphagia a risk of cancer and stricture.

Difficulty swallowing is a symptom for which time matters. Most causes are treatable, and early diagnosis — whether eosinophilic oesophagitis, achalasia or malignancy — reduces the risk of complications such as permanent oesophageal narrowing, aspiration or malnutrition. The most sensible approach is to arrange an assessment before the symptom becomes the “norm”.