This is a UKMLA-centred history guide about swallowing problems.

Introduction

Difficulty swallowing can be categorised into three subgroups as described by patients: 

• Dysphagia
• Odynophagia
• Globus

The definition of dysphagia is difficulty in swallowing. Dysphagia can be further broken down into difficulty swallowing solids, liquids, or both, and by the position where swallowing becomes difficult.

Odynophagia is painful swallowing and can make it difficult to swallow.

Globus is the sensation of feeling a lump in your throat even though a physical lump is not present. This condition is benign.

In this article we will explore how to take a focused history on dysphagia.

Structural and Functional Causes of Dysphagia

Causes of dysphagia can be broken down into:

• ‘Structural’ – refers to a physical obstruction, such as a mass, cancer or stricture causing dysphagia.
• ‘Functional’ – refers to the absence of physical abnormalities with swallowing, where the patient cannot initiate, coordinate or complete the process of swallowing. This is often caused by a neurological condition.

Below is a list of some structural and functional causes of dysphagia further broken into upper vs lower dysphagia: 

Presenting Complaint

Try to expand on the presenting complaint by asking the following questions:

Site

• Where is the food actually getting stuck?
• Upper i.e. the mouth, or lower, towards the stomach.
• Differentials for upper dysphagia are cancer, pharyngeal pouch, stroke, motor neurone disease, and multiple sclerosis.
• Differentials for lower dysphagia are achalasia, GORD, cancer, oesophageal strictures, and mediastinal masses.

Onset

• Has the dysphagia come on suddenly, or has it slowly gotten progressively worse?
• The main differential to keep in mind for progressive dysphagia is cancer until proven otherwise.
• Progressive dysphagia is highly suggestive of a stricture (benign or malignant) but can also be seen in achalasia, MND, and myasthenia gravis.

Timing

• Consider the duration of symptoms, and if the symptoms are constant or intermittent.
• Intermittent dysphagia typically occurs in motility disorders like achalasia, diffuse oesophageal spasms, and CREST syndrome.
• Constant dysphagia typically occurs in cancer and advanced motility disorders.

Associated Symptoms

• Ask about the FLAWS symptoms (fatigue, lethargy, anorexia, weight loss, and night sweats) to screen for cancer.
• Ask the patient if they had any weakness or numbness, any fits, faints or funny turns and any changes in hearing, vision, and balance and motor function to screen for neurological conditions causing their dysphagia.
• Ask about reflux of food contents, nausea and vomiting, gurgling

Other Useful Questions

• Ask patients if they use NSAIDs, have a history of reflux or peptic ulcer disease.
• Does anything make symptoms better or worse?
• Is the dysphagia for liquids, solids, or both?

Common Causes of Dysphagia

When a patient presents with dysphagia, we always want to rule out upper GI malignancy and neurological causes because these are the most common and most serious for the patient. Below are some of the common causes:

Background

Past Medical History

• GORD – reflux of gastric contents can cause irritation of the oesophagus and make it painful to swallow and reduce the ability to swallow.
• Peptic ulcers can cause gastric outlet obstruction leading to dysphagia.
• Gastrointestinal surgery, GORD, and Barrett’s oesophagus are risk factors for developing oesophageal cancer.
• Neuromuscular disease affects the muscles used in swallowing, e.g. motor neurone disease and Parkinson’s.
• Cardiovascular and cerebrovascular disease history are risk factors for strokes.
• A recent history of gastroenteritis presenting with other neurological signs can be suggestive of Guillain-Barré syndrome.
• Rheumatological disease – CREST Syndrome affects oesophageal motility and swallowing function.

Drug History

• Calcium-channel blockers and nitrates relax smooth muscle and can worsen reflux.
• NSAIDs, steroids, and bisphosphonates predispose patients to peptic ulceration and reflux.

Social History

• Alcohol consumption and smoking increase the risk of oesophageal malignancy.
• Travel History – recent travel to South America should raise suspicion for Chagas disease, a cause of achalasia.
• Diet – changes in appetite can be a red flag symptom for malignancy.
  • If their symptoms worsen when consuming fried food, fast food, fatty and heavy meals, this can suggest reflux or peptic ulcer disease. 
  • If milk and dairy products improve their symptoms, this can suggest heartburn from reflux and peptic ulcer disease.

Family History

• Oesophageal carcinoma
• Peptic ulcer disease and gastrinoma
• Neuromuscular disease

References
 
1. Oxford Clinical Cases in Medicine and Surgery

2. Dysphagia Oxford Medical Education: https://oxfordmedicaleducation.com/gastroenterology/dysphagia/

3. Passmedicine Extended Textbook: https://passmedicine.com/

Author – Bharneedharan Surendaran  

Editor – Dr James Mackintosh

Last updated 27/01/2026