Swallowing Cancer of the oesphagus is the most serious problem that leads to difficulty swallowingCandida or thrush of the oesophagus can cause pain on swallowing. This problem may follow antibiotic treatmentEosinophilic oesophagitisA fibrous ring at the lower end of the oesophagus can causes solid food like meat to block the oesophagus causing acute chest painDifficulty swallowing or "food sticking" Recent onset of difficulty with swallowing needs urgent attention. There should be an examination of the gullet (oesophagus) as soon as possible. This test is called a gastroscopy. The main worry here is to check for cancer of the oesophagus. Early diagnosis is crucial. Lump in the throat sensation is not the same as difficulty swallowing - see below. Causes of difficulty swallowing Problems with swallowing that have been occurring over many years are usually due to a motility disorder. That is, there is a problem with co-ordination of the muscles that convey the food from the mouth to the stomach. There are limited treatments for this situation and the need for further tests will depend on the situation. It is important that a gastroscopy is performed to exclude any partial obstruction. Further investigation with barium swallow and pressure studies of the oesophagus (manometry) can be helpful. Achalasia is a progressive motility disorder that does have effective treatment. The key symptoms is progressive difficulty in swallowing for both liquids and solids Eosinophilic oesophagitis Eosinophilic oesphagitis is a condition that is increasingly being recognized - perhaps increasing in frequency in the last 20 years This condition is a type of allergic condition where this is increased stiffness of the oesphagus leading to difficulty swallowing. This is the main cause of food bolus obstruction - the complete blockage of the oesphagus from food - usually meat or bread. This condition is diagnosed by gastroscopy and biopsy of the oesophagus The initial approach should be regular omeprazole or pantoprazole even if there are no symptoms of heartburn as acid can be the initiating factor for this allergic reaction. The next treatment is topical steroids. This can be achieved by using a high dose steroid inhaler (as used for asthma) and attempting to swallow rather than inhale the medication. Other solutions using budesonide liquid mixed with a viscous agent work - not available in NZ. Other treatments are being developed. Dietary exclusions based on elimination of common foods that cause allergy or based on allergy testing can be effective for children but much less effective in adults The other main cause of partial obstruction is a stricture resulting from acid reflux over many years. Sometimes there can be a fibrous web that may not be related to acid reflux. Both conditions are well treated with investigation by gastroscopy, then a dilatation at the time of gastroscopy if necessary. Tablets to reduce acid (omeprazole) are usually required in the long-term. The main worry with the symptom of difficulty swallowing is the diagnosis of cancer of the oesophagus. This is an uncommon problem although this cancer is gradually becoming more common. This is because long-term reflux symptoms can be a risk factor and reflux is becoming more common in our community - partly because of increasing obesity. This related to the problem of Barretts oesophagus - see heartburn section Cancer of the oesophagus is a serious condition that needs urgent review by an experienced surgeon and an oncologist. The diagnosis is easily made at the time of a gastroscopy. Any swallowing problem that is gradually getting worse needs further attention (i.e. a gastroscopy). If the gastroscopy is normal then a video barium swallow (X-ray) is a next investigation. There is a rare condition called achalasia which leads to failure of the lower oesophageal sphincter to open appropriately to let the food bolus though to the stomach. This is usually picked up on barium swallow but may require a specialized test called oesophageal manometry. Treatment is usually a laparoscopic operation where the muscle of the lower oesophageal sphincter (or "valve") are divided. Pain on Swallowing /lump in the throat Pain in the centre of the chest immediately after swallowing may suggest ulceration in the oesophagus. This can be due; to acid reflux. due to medication causing irritation or may be due to an infection in the oesophagus. A common medication to cause ulceration is tetracycline (doxycycline, minocycline). Sometimes the symptom is simply a sensitive oesophagus. The symptoms may be reduced by stopping coffee, alcohol and citrus juices. A lump in the throat sensation (sometimes called globus) is not associated with any disease The symptom is rarely due to reflux. All tests are generally normal. Sometimes oesophageal pH testing is required to prove that there is no acid reflux. This symptom may be related to stress. It commonly follows a stressful life event, often lasting for several months , then settling without treatment. There is no value in taking acid reducing medication such as omeprazole.