When should trouble swallowing be taken seriously?

Perhaps for some time food has been sticking in your throat or the middle of your chest, and you wash it down with water. Many people put this down to habit or eating in a hurry. This article helps you understand what trouble swallowing means, what may lie behind it, and when it must be followed up.

What does trouble swallowing mean?

Doctors call it dysphagia. MedlinePlus describes it as a problem that makes swallowing hard or painful. Some patients cannot swallow at all. Drinks, solid food or even saliva may be a problem. The NHS writes that some people have trouble only with certain foods or drinks, and some cannot swallow at all.

Signs the NHS names:

• coughing or choking when eating or drinking
• food coming back up into the mouth, sometimes through the nose
• a feeling of food stuck in the throat or chest
• a wet, gurgly voice after eating or drinking
• drooling and difficulty chewing

If the problem continues, the NHS warns that it can lead to weight loss, dehydration and repeated chest infections. MedlinePlus also says it can become hard to get enough calories and fluid.

Why does it happen?

The NHS says trouble swallowing is usually the result of another condition or problem and can happen at any age. MedlinePlus adds that it is more common in older people. Causes these two sources name:

• Acid reflux and inflammation of the oesophagus, including eosinophilic oesophagitis
• Diseases of the nerves and brain such as stroke, Parkinson’s disease, dementia, multiple sclerosis and cerebral palsy
• A movement disorder of the oesophagus such as achalasia. MedlinePlus says that in achalasia, nerve damage in the oesophagus stops the lower valve relaxing properly, so food reaches the stomach more slowly. It is a rare condition.
• Some medicines, for example antipsychotics (NHS)
• Lung disease such as COPD (NHS)
• Cancer of the mouth, throat or oesophagus and the effects of earlier cancer treatment

So trouble swallowing on its own does not mean cancer. About the symptoms of oesophageal cancer, the NHS writes that these symptoms are very common, have many causes, and having them does not necessarily mean cancer. At the same time, the same source lists trouble swallowing among the symptoms of oesophageal cancer and wants anyone with it to see a doctor. Both statements are true, which is why a doctor, not our own guess, should find the cause.

When to take it seriously

Trouble swallowing that continues or gets worse. In its oesophageal cancer page the NHS lists trouble swallowing among the things to tell a GP, as well as symptoms that are getting worse or are unusual for you. The same page warns that you may get used to these symptoms.

Signs that need a doctor sooner. The NHS dysphagia page suggests an urgent appointment for: trouble swallowing, coughing or choking when eating, food coming back up, breathlessness after eating and repeated chest infections. The NHS also counts noticeable weight loss, heartburn on most days lasting at least three weeks, and a cough that will not clear among the reasons to see a doctor.

Signs that cannot wait for an appointment.

• Choking or severe breathlessness when eating. If breathing has become very hard, call 115, Iran’s emergency number.
• Vomiting blood. The NHS says medical help is always needed, so go to the emergency department straight away. If it comes with dizziness, pallor, cold sweat, fast breathing, confusion, stomach pain or black stools, call 115, Iran’s emergency number. Do not drive yourself, and take your medicines with you.
• Black or dark red stools. The NHS advises urgent medical help, which means calling a doctor the same day.
• Vomiting for more than two days. Call a doctor the same day (NHS).
• Not being able to swallow water. The NHS lists dehydration among the results of trouble swallowing. If even water will not go down, tell a doctor the same day. If you cannot even swallow your saliva, or food is stuck and will not go down, go to the emergency department straight away.

See the full list in the guide When should I call urgently?

How does the doctor investigate?

First there is an examination and questions about the problem. The NHS says a doctor may send you to hospital for more tests. MedlinePlus lists these tests:

• Upper endoscopy (EGD). A soft tube with a camera that shows the lining of the oesophagus and stomach.
• Barium swallow. X-rays taken while you swallow a substance that shows up on the image.
• Oesophageal manometry. Measures how the muscles of the oesophagus work.
• A bedside swallowing assessment and a swallowing study using fluoroscopy.

Which you need depends on your symptoms and the findings on examination. If endoscopy shows a mass, a biopsy and imaging such as CT may be considered too.

What is the treatment?

The NHS says treatment depends on the cause and severity of the problem. If the cause is something like acid reflux, the problem may get better by itself, but you still need to be checked. Ways the NHS and MedlinePlus describe:

• medicine for reflux or eosinophilic oesophagitis
• swallowing exercises with a speech and language therapist or swallowing specialist
• changes in the type of food, such as softer food or thickened drinks
• a feeding tube in serious cases
• stretching the oesophagus, or an injection to relax the oesophageal muscle
• surgery in some cases. About achalasia, MedlinePlus says surgical and non-surgical approaches give similar results and the choice is made according to the patient’s situation.

Most patients first see a GP, an internist or a gastroenterologist. A surgeon may become involved when, for example, a blockage in the oesophagus has to be removed (NHS) or a movement disorder of the oesophagus or a tumour needs surgery. Being referred to a surgeon does not mean an operation is certain. There is more on the page about oesophageal disease and trouble swallowing.

Until you see a doctor

• Write down when it started, whether solid food is hard or liquids too, whether you have coughing or food coming back up, and how much weight you have lost.
• Take your medicine list with you. Do not stop or change a medicine yourself because of this problem. The NHS names some medicines among the causes of trouble swallowing, but the decision about medicines is your doctor’s.
• If you cough or choke when eating, be sure to tell the doctor.
• Ask your doctor about swallowing therapy. The support page names ‘swallowing therapy’ among the services in the patient support form.
• Gather your earlier records, including endoscopy results or images. The first visit guide has the full list.

Questions you can ask

• What do you think is causing my problem, and what test is needed to find out?
• What should I eat and avoid until then?
• Do I also need to see a gastroenterologist, a speech therapist or a surgeon?
• What sign should make me come back sooner?