Reasoning GP · Algorithm · 1-page summary
Dysphagia (difficulty swallowing) in adults
For: adults with new difficulty swallowing, oropharyngeal or oesophageal, face to face or remote. Not for: a lump sensation with normal swallowing (globus, block 4) or children. Reflux without dysphagia → GORD protocol.
Core rule: unexplained dysphagia at any age → suspected cancer pathway referral for oesophageal or stomach cancer (NG12). Never delay it to trial a PPI. Localise and investigate alongside the referral, never instead of it.
0Stop — call 999 now — or transfer to hospital now
- Can't swallow saliva, drooling or persistent regurgitation (complete obstruction, food bolus) → immediate hospital transfer Same-day for urgent endoscopy; airway compromise, respiratory distress, severe chest pain, suspected perforation or instability → 999
- Haematemesis: active, with instability or known varices → 999; otherwise, or melaena → Same-day hospital
- Chest pain with dysphagia: suspected ACS or aortic dissection → 999. Troponin is a hospital test. Suspected acute stroke → 999 via the stroke pathway.
- While waiting: no blind removal, no forced oral fluids; stroke → nil by mouth, no oral medicines or fluids until a swallow screen (NG128).
1Triage by route — if block 0 is clear
| Presentation | Route |
|---|---|
| Any unexplained dysphagia | Any age, with or without weight loss → Suspected cancer pathway upper GI; OGD via the pathway |
| Aspiration, unwell | Respiratory compromise, hypoxia, sepsis or can't maintain hydration → Same-day hospital |
| Neck mass | Or lump in throat + hoarseness + weight loss → Suspected cancer pathway head and neck; unsure of level → refer both |
| Clearly neurological | → SALT plus stroke pathway, neurology or ENT as the presentation needs |
2Screen — one row is enough
- Food impaction now, managing secretions → Same-day hospital. Recurrent food bolus → Urgent gastroenterology.
- Aspiration signs (wet voice, coughing at meals, recurrent chest infections), well → Urgent SALT and dietetic assessment
- Severe weight loss with inability to swallow fluids → Same-day
- Dysarthria, tongue fasciculation, fatigable swallow (MND, myasthenia, Parkinson's) → Urgent neurology and SALT
- Aged ≥55, weight loss plus upper abdominal pain, reflux or dyspepsia → Suspected cancer pathway (NG12)
3Assess — alongside the referral
☐ Weight, BMI, % weight loss, MUST ☐ Mouth: candida, teeth, mass ☐ Neck: nodes, thyroid, pouch ☐ Neuro: dysarthria, wet voice, tongue fasciculation ☐ Chest, SpO₂ ☐ Abdomen: epigastric mass, liver
Targeted bloods (FBC, ferritin if anaemia, U&E, LFTs). OGD comes via the referral. Not in primary care: CT staging, manometry. CXR only if aspiration or chest disease suspected.
4Classify — a probability, never a reason not to refer
- Oropharyngeal — trouble starting the swallow, choking at onset, nasal regurgitation → SALT; treat the neuro cause.
- Mechanical — solids then liquids, progressive → cancer, peptic stricture, ring → suspected cancer pathway.
- Motility — solids and liquids from onset, long history (achalasia, spasm) → OGD first; gastroenterology arranges manometry.
- Eosinophilic oesophagitis — young, atopic, food impaction → OGD with biopsies, gastroenterology.
- Pharyngeal pouch — late regurgitation, halitosis, gurgling → ENT / upper GI. Globus — lump sensation only; food and liquids pass, no alarm features.
- Uncertain — refer on the suspected cancer pathway. Never label it reflux or globus.
5Treat today — only these
- Prominent reflux: a PPI may be given for symptoms while the referral proceeds; document it and tell the endoscopy service.
- Oral candidiasis: miconazole oral gel first line (nystatin if unsuitable or on warfarin), or systemic antifungal if extensive; fluconazole interacts with warfarin and QT-prolonging medicines.
- Pill oesophagitis: review the culprit (bisphosphonate, doxycycline, NSAID, iron, KCl) with the prescriber; take with water, upright.
- Nutrition: supplements via a dietitian or local ACBS criteria, safe for the swallow; texture or fluid change (IDDSI) only as SALT recommends. Doses: NICE/SPC, BNF, local formulary.
6Refer routinely
- Suspected oropharyngeal dysphagia → SALT (urgent for stroke, MND or aspiration).
- Suspected achalasia or motility disorder, EoE, GORD not responding to PPI → gastroenterology.
- Smoking and alcohol: advise stopping; stop smoking service.
7Never reassure by
- A response to a PPI.
- Young age: dysphagia has no age threshold.
- No weight loss: it adds urgency but is not needed.
- An intermittent or long-standing history.
- Where the patient feels the hold-up: a throat sensation can be distal.
- Calling it globus when food or liquids stick.
8Safety-net — say it, then document it
999 “Call 999 if you can't swallow your saliva, choke and struggle to breathe, vomit blood, or get sudden severe chest pain.” Same day: “Contact us today if swallowing gets quickly worse, you cough or choke with a fever, or your weight is falling faster.”
Referral: confirm it was received and explain the local time frame; chase if not heard. Do not wait for the appointment if swallowing deteriorates or intake cannot be maintained.
✓Safe to leave primary care only if — all five, documented
No block 0–2 row applies
Suspected cancer pathway referral sent, not delayed for a PPI
Weight, MUST, hydration and aspiration risk recorded
SALT, neurology or head and neck route added if needed
Safety-net given; referral tracked, owner named
Summary of the full Reasoning GP dysphagia algorithm, which holds the detail, examination, investigations and evidence. Sources: NICE NG12 (updated April 2026), NG128, CG184; BSG; RCSLT; IDDSI; current SPC and local formulary. Clinical reference — follow local upper-GI emergency, stroke and SALT pathways and check doses: NICE/SPC, BNF.