Dysphagia (Difficulty Swallowing)
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Overview
Dysphagia is the medical term for difficulty swallowing — the feeling that food or liquid is slow to pass, gets stuck, or "goes down the wrong way." It is a symptom, not a diagnosis, and it is surprisingly common: in a large U.S. population survey, about one in six adults reported some degree of swallowing difficulty (Adkins et al., Clinical Gastroenterology and Hepatology, 2020). Many of them never sought care.
Doctors divide dysphagia into two main types:
- Oropharyngeal dysphagia: trouble starting a swallow and moving food from the mouth into the esophagus. It often causes coughing, choking or nasal regurgitation and is usually related to neurologic or muscular conditions, such as stroke or Parkinson's disease, or to a Zenker's diverticulum.
- Esophageal dysphagia: food feels stuck in the lower throat or chest seconds after swallowing. It is caused by a mechanical narrowing (such as a stricture, ring, tumor or tight anti-reflux wrap) or by a motility disorder in which the esophageal muscle does not move food properly.
New or progressive difficulty swallowing should always be evaluated, because a small number of cases are caused by cancer and many common causes — strictures, eosinophilic esophagitis, hiatal hernias and achalasia — are highly treatable. The right treatment depends entirely on finding the right cause.
Causes
Mechanical (structural) causes
- Peptic strictures and Schatzki rings from long-standing reflux
- Eosinophilic esophagitis, a leading cause of food impaction in younger adults
- Esophageal cancer or cancer at the top of the stomach
- Paraesophageal and large hiatal hernias
- Esophageal diverticula, including Zenker's diverticulum
- Surgical causes: a tight or herniated wrap after anti-reflux surgery (failed fundoplication), a LINX device, or a stricture after bariatric surgery.
- Pill, caustic or radiation injury
- External compression from enlarged blood vessels, lymph nodes or tumors
Motility (muscle and nerve) causes
- Achalasia
- EGJ outflow obstruction
- Diffuse esophageal spasm and jackhammer esophagus
- Ineffective esophageal motility and scleroderma
- Opioid-induced esophageal dysfunction
Reflux-related causes
- GERD and erosive esophagitis, which cause inflammation and swelling
- Esophageal ulcers
Oropharyngeal causes
- Stroke, Parkinson's disease, ALS, myasthenia gravis and muscular disorders
- Head and neck cancer or radiation
- Cricopharyngeal muscle dysfunction
Risk Factors
- Older age
- Long-standing heartburn or reflux
- Allergic conditions such as asthma and eczema (for EoE)
- Smoking and heavy alcohol use
- Neurologic disease
- Prior foregut, bariatric or neck surgery
- Radiation to the head, neck or chest
- Chronic opioid use
Who It Affects
Dysphagia can affect anyone but becomes more common with age. Younger adults with food impaction frequently have eosinophilic esophagitis or a ring. Middle-aged and older adults more often have strictures, hiatal hernias, motility disorders or, less commonly, cancer. Patients who have had anti-reflux or bariatric surgery are a distinct group whose swallowing problems are often related to the anatomy created by surgery.
Complications
- Food impaction
- Aspiration pneumonia
- Malnutrition, dehydration and weight loss
- Delayed diagnosis of cancer when symptoms are ignored
- Reduced quality of life and social avoidance of meals
Symptoms
- Food sticking in the throat or chest
- Pain with swallowing
- Coughing or choking when eating or drinking
- Regurgitation of undigested food
- Needing to wash food down with liquids
- Drooling or difficulty handling saliva
- Heartburn
- Hoarseness
- Unintentional weight loss
- Recurrent pneumonia from aspiration
Clues to the cause: difficulty with solids only that gets steadily worse suggests a mechanical narrowing; trouble with both solids and liquids from the start suggests a motility disorder; intermittent food sticking in a young adult with allergies suggests EoE.
Diagnosis
Evaluation is tailored to the type of dysphagia:
- History and examination: what is hard to swallow, where it sticks, how long it has been happening, and whether there is weight loss.
- Upper endoscopy with biopsies: the first test for most esophageal dysphagia, identifying strictures, rings, tumors, esophagitis and EoE, and often allowing treatment in the same session. See diagnostic upper endoscopy.
- Barium esophagram: shows the anatomy, emptying, hernias and diverticula. A timed esophagram measures how well the esophagus empties.
- High-resolution esophageal manometry: the key test when endoscopy is normal, diagnosing achalasia and other motility disorders (Yadlapati et al., Neurogastroenterology & Motility, 2021).
- pH or pH-impedance testing: measures reflux.
- CT scan: for suspected masses or complex anatomy.
- Modified barium swallow and speech-language evaluation: for oropharyngeal dysphagia.
Differential Diagnosis
- Globus sensation: a lump-in-the-throat feeling without true difficulty swallowing
- Odynophagia: painful swallowing from infection or ulcers
- Functional heartburn and functional dysphagia, when testing is normal
- Laryngopharyngeal reflux
- Cardiac or lung conditions causing chest symptoms
Lifestyle Modifications
- Take small bites and chew thoroughly.
- Eat slowly and sit upright during and after meals.
- Alternate solids with sips of liquid.
- Choose softer, moist foods until the cause is treated.
- Take pills upright with a full glass of water.
- Do not ignore worsening symptoms or weight loss.
Treatment Options
Treatment is directed at the cause:
- Strictures and rings: endoscopic dilation, plus acid control.
- Eosinophilic esophagitis: acid suppression, swallowed steroids, diet therapy, biologics and dilation.
- Achalasia and outflow obstruction: Heller myotomy, POEM or pneumatic dilation.
- Spastic disorders: medications, botulinum toxin or myotomy.
- Paraesophageal hernia: laparoscopic hernia repair.
- Reflux: medication or anti-reflux surgery.
- Failed or tight fundoplication: dilation or revisional surgery.
- Zenker's diverticulum: endoscopic or surgical division of the cricopharyngeus muscle.
- Cancer: staging and multidisciplinary treatment, which may include esophagectomy.
- Oropharyngeal dysphagia: swallowing therapy with a speech-language pathologist and treatment of the underlying condition.
When to See a Doctor
See a doctor for any swallowing difficulty that lasts more than a few weeks, gets worse, or comes with weight loss, vomiting, anemia or bleeding — these are warning signs that need prompt endoscopy. Go to the emergency room if food is stuck and you cannot swallow your saliva, or if you are choking or having trouble breathing.
When to Seek Treatment
Seek evaluation by a foregut specialist when an initial endoscopy is normal but symptoms persist, when dilations keep failing, when you have had prior anti-reflux or bariatric surgery, or when surgery is being considered. Manometry and esophagram are often the missing pieces.
Swallowing Problems After Anti-Reflux or Bariatric Surgery
Some difficulty swallowing is normal for several weeks after a fundoplication, LINX placement or hiatal hernia repair while swelling settles. Swallowing that does not improve after six to eight weeks, or that returns months or years later, may mean the wrap is too tight, has slipped, or has herniated — see failed fundoplication and recurrent hiatal hernia. After a sleeve gastrectomy or gastric bypass, food sticking or vomiting can signal a stricture, a twisted sleeve, or a hiatal hernia. These problems are best evaluated by a surgeon familiar with both the original operation and the options for revision.
Long-Term Outlook
Some conditions, such as EoE and achalasia, need long-term follow-up. Treating the underlying problem — rather than repeating dilations alone — gives the most durable results. Report any return of symptoms early so treatment can be adjusted.
More Foregut and Reflux Conditions
Explore related topics in our foregut patient library: Achalasia, EGJ Outflow Obstruction, Jackhammer Esophagus, Peptic Ulcer Disease, GERD (Acid Reflux) and Functional Heartburn. For an overview of surgical options, see anti-reflux surgery and hiatal and paraesophageal hernia repair.
Related Reading and Videos
Watch The Reflux Talk Every Patient Needs: Hiatal Hernias, Warning Signs & What Doctors Don’t Explain on our video library. Treatments that may be involved include Esophageal Dilation (Endoscopic Balloon & Bougie Dilation for Strictures & Dysphagia), POEM (Peroral Endoscopic Myotomy) and Laparoscopic Heller Myotomy (Heller-Dor Surgery for Achalasia).
Prognosis
The outlook depends on the cause, but most causes of esophageal dysphagia are benign and treatable. Strictures, rings, EoE, hiatal hernias and achalasia all respond well to targeted treatment, and most patients return to a normal or near-normal diet.
Why Choose Dr. de la Cruz‑Muñoz
Swallowing problems often have more than one contributing cause, and many patients have already had a "normal" endoscopy without an answer. Dr. Nestor de la Cruz-Muñoz, MD, FACS, DABOM, is a board-certified surgeon specializing in minimally invasive foregut and bariatric surgery in Miami who directed a bariatric surgery fellowship for 10 years, training 13–14 fellows who also gained experience in foregut surgery. He evaluates dysphagia with the full set of tests — endoscopy, esophagram, manometry and pH testing — and treats the cause, whether that is dilation, hiatal hernia repair, myotomy, or revision of a prior operation. Patients traveling from outside South Florida are welcome.
Dr. de la Cruz-Muñoz has performed more than 15,000 minimally invasive procedures over more than 25 years in practice, including complex foregut, hernia, gallbladder and abdominal operations as well as bariatric surgery.
Featured Procedures
FAQ
The most common causes of trouble swallowing in adults are narrowings of the esophagus (peptic strictures and Schatzki rings from long-standing reflux), eosinophilic esophagitis, hiatal and paraesophageal hernias, and muscle disorders such as achalasia. Less often, a tumor is responsible, which is why new swallowing problems should always be checked. Problems starting a swallow — coughing, choking or food going into the nose — usually come from the throat and are often related to neurologic conditions, while food sticking in the chest points to the esophagus.
Go to the emergency room if food is stuck and you cannot swallow your own saliva, if you are choking or having trouble breathing, or if you vomit blood. Food impaction usually needs an endoscopy within hours to remove the food safely. You should also see a doctor promptly — though not necessarily in the emergency room — if swallowing difficulty is getting steadily worse or comes with unexplained weight loss, anemia or black stools, because these are warning signs that need an endoscopy soon.
A normal endoscopy rules out many causes, such as tumors and severe inflammation, but it cannot measure how the esophageal muscle works. Achalasia, EGJ outflow obstruction and spastic disorders are often missed for years because the lining looks normal. The next tests are usually high-resolution esophageal manometry, which measures the pressure and coordination of each swallow, and a timed barium esophagram, which shows how well the esophagus empties. Biopsies are also important even when the lining looks normal, because eosinophilic esophagitis can be subtle on camera (Dellon et al., Gastroenterology, 2018).
Yes. Long-standing reflux can inflame the lower esophagus and, over time, scar it into a narrowing called a peptic stricture. Reflux can also cause swelling that makes food feel slow to pass, and a hiatal hernia that often accompanies reflux can trap food at the diaphragm. Strictures are treated with endoscopic dilation and acid control, and patients whose reflux keeps causing damage may benefit from anti-reflux surgery to treat the problem at its source. Because reflux and eosinophilic esophagitis can look alike, biopsies are usually taken at endoscopy.
Some difficulty swallowing is expected for about four to eight weeks after a fundoplication, LINX or hiatal hernia repair while swelling at the repair settles, which is why patients follow a liquid and soft-food diet at first. Swallowing that does not improve after about two months, gets worse, or returns months or years later should be evaluated. Causes include a wrap that is too tight, has slipped, or has herniated back into the chest. Many of these problems respond to dilation, and others are corrected with revisional surgery.
Diagnosis usually starts with an upper endoscopy to rule out narrowing, tumors or inflammation. The key test is high-resolution esophageal manometry, which measures the pressure and coordination of the esophageal muscle with each swallow and classifies disorders such as achalasia, EGJ outflow obstruction, diffuse esophageal spasm and jackhammer esophagus (Yadlapati et al., Neurogastroenterology & Motility, 2021). A timed barium esophagram shows how well the esophagus empties, and pH testing checks for reflux.
An esophageal diverticulum is a pouch that bulges out from the wall of the esophagus. The most common type, Zenker's diverticulum, forms at the top of the esophagus; others form in the middle (mid-esophageal) or just above the stomach (epiphrenic). Many are caused by underlying muscle dysfunction. Symptoms include difficulty swallowing, regurgitation of undigested food, bad breath, coughing and aspiration. Small, symptom-free diverticula can be watched, while symptomatic ones are treated endoscopically or surgically, often with a myotomy.
An esophageal stricture is a narrowing of the esophagus that makes it hard for food to pass. Most are caused by scarring from long-standing acid reflux (peptic strictures). Other causes include Schatzki rings, eosinophilic esophagitis, pill or caustic injury, radiation, surgical connections and, less often, cancer. The main symptom is gradually worsening difficulty swallowing solid foods. Strictures are diagnosed with endoscopy and treated with dilation, along with treatment of the underlying cause.
