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Esophageal and Oropharyngeal Dysphagia: Clinical Recommendations From the United European Gastroenterology and European Society for Neurogastroenterology and Motility

UEG/ESNM · 2025 · Europe

Source and licence

Authors
Amir Mari, Francesco Calabrese, Andrea Pasta et al.
Title
Esophageal and Oropharyngeal Dysphagia: Clinical Recommendations From the United European Gastroenterology and European Society for Neurogastroenterology and Motility
Journal
United European Gastroenterology Journal, 2025
DOI
10.1002/ueg2.70062
Licence
CC BY 4.0
Changes
Verbatim excerpts; formatting adapted

Full text retrieved 2026-10-27 from Europe PMC · PMC12269739

Licence statement of the original publication

This is an open access article under the terms of the http://creativecommons.org/licenses/by/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

This page reproduces excerpts of the original publication; the original is authoritative. It has not been reviewed by a physician, does not state a recommendation of Medelix and does not replace medical advice. The guideline may have been updated since.

Open the original publication →Full text on Europe PMC

Recommendations

Verbatim, with grade of recommendation or strength of consensus where given.

Section 1: Definition and Epidemiology

  • Statement 1.1UEG/ESNM propose the following definition of esophageal dysphagia: a difficulty swallowing generally sensed retrosternally and related to the esophagus or its lower esophageal sphincter (LES) caused by anatomical, mechanical or functional abnormalities.Quality of evidence: very low; recommendation: expert opinion
  • Statement 1.2UEG/ESNM recognize that OD is defined as a swallowing dysfunction that causes impairment in moving the bolus safely and effectively from the mouth through the pharynx into the esophagus. The main signs are divided into safety (airway penetration and aspiration) or efficacy (prolonged swallow response, impaired labial seal, premature spillage in the pharynx, piecemeal deglutition, nasal regurgitation, oral or pharyngeal residue and impaired upper esophageal sphincter opening) swallowing impairments. The main accompanying symptoms include cough, choking, fear of eating, voice change, globus, prolonged meal duration, fatigue, and reduced pleasure of eating.Quality of evidence: very low; recommendation: expert opinion
  • Statement 1.3UEG/ESNM recognizes that the general prevalence of dysphagia is estimated to be between 10% and 20%, depending on the definition used and the population included. Notably, no studies have assessed esophageal dysphagia prevalence as a separate concrete entity, therefore it is not possible to estimate its true prevalence.Quality of evidence: very low; recommendation: expert opinion
  • Statement 1.4UEG/ESNM recognize that the prevalence of OD varies according to the target population. Elderly patients, patients with neurological or neurodegenerative diseases, and patients with head or neck diseases have the highest prevalence.Level of evidence: moderate, grade of recommendation: good practice statement
  • Statement 1.5UEG/ESNM recognize that OD is associated with higher hospital stays and costs as well as higher probability of being transferred to post‐acute care facilities such as nursing homes. Moreover, the development of nutritional and respiratory complications, such as malnutrition and respiratory infections, has been associated with an independent increase in long‐term costs for follow‐up, especially in post‐stroke patients.Level of evidence: moderate, recommendation: good practice statement

Section 2: Physiopathology and Related Conditions

  • Statement 2.1UEG/ESNM recognize that a wide range of systemic neuromuscular, rheumatological/immunological, endocrinological, and infectious diseases can be associated with esophageal and/or OD.Level of evidence: moderate, recommendation: good practice statement
  • Statement 2.2UEG/ESNM recognize that motility disorders identified on HRM are generally associated with symptoms, primarily dysphagia.Level of evidence: high, grade of recommendation: strong
  • Statement 2.3UEG/ESNM recognize that spastic (premature) esophageal contraction is a mechanism underlying the symptoms of esophageal dysphagia.Level of evidence: low, grade of recommendation: weak
  • Statement 2.4UEG/ESNM recognize that hypercontractile motility is a mechanism underlying symptoms of esophageal dysphagia.Level of evidence: moderate, grade of recommendation: weak
  • Statement 2.5UEG/ESNM recognize that IEM is a mechanism underlying symptoms of esophageal dysphagia.Level of evidence: low, grade of recommendation: weak
  • Statement 2.6UEG/ESNM recognize that esophageal hypersensitivity is a mechanism underlying symptoms of esophageal dysphagia.Level of evidence: very low, grade of recommendation: weak
  • Statement 2.7UEG/ESNM recognize that decreased EGJ distensibility is a mechanism underlying symptoms of esophageal dysphagia.Level of evidence: high, grade of recommendation: strong
  • Statement 2.8UEG/ESNM recognize that impaired LES relaxation is a mechanism underlying the symptoms of esophageal dysphagia, apart from achalasia.Level of evidence: moderate, grade of recommendation: strong
  • Statement 2.9UEG/ESNM recognize that esophageal dysmotility may predispose to disorders like epiphrenic diverticulum, candida esophagitis and strictures.Level of evidence: very low, GRADE of recommendation: weak
  • Statement 2.10UEG/ESNM recognize that the main phenotypes of patients with OD are older adults, patients with neurological and neurodegenerative diseases, patients with head and neck cancer (pre‐ or post‐treatment), and patients with anatomical/structural alterations. A less prevalent group includes patients with infectious or metabolic diseases, side effects of drugs, or iatrogenic conditions.Level of evidence: high, grade of recommendation: good practice statement
  • Statement 2.11UEG/ESNM recognize that patients with OD have impaired biomechanics of the oropharyngeal swallow response, including delayed total deglutition time, delayed time to laryngeal vestibule closure, delayed UES opening, and reduced bolus kinematics (propulsion force and bolus velocity). Neurophysiologically, they exhibit impairments in both afferent (sensory) and efferent (motor) pathways. Additionally, specific structural changes in the oral cavity, pharynx, larynx, and UES can lead to the development of structural OD.Level of evidence: moderate, recommendation: good practice statement
  • Statement 2.12UEG/ESNM recognize that OD is associated with serious nutritional and respiratory complications, including malnutrition, dehydration, and respiratory infections such as aspiration pneumonia. These complications are linked to poor health outcomes, including hospital readmissions and increased morbidity and mortality.Level of evidence: moderate; recommendation: good practice statement
  • Statement 2.13UEG/ESNM recognize dysphagia and anxiety/depression can be associated conditions. While this link is well addressed in the case of OD, data on esophageal dysphagia are scarce.

Section 3: Diagnosis

  • Statement 3.1UEG/ESNM recommends careful focused history taking, although it is insufficient to differentiate between esophageal and OD.Quality of evidence: very low; recommendation: expert opinion
  • Statement 3.2UEG/ESNM recommend upper gastrointestinal endoscopy (EGD) to evaluate esophageal dysphagia in all adult patients. EGD also plays a pivotal role in cases of acute onset of inability to swallow, which suggests a food impaction in the esophagus.Level of evidence: low, grade of recommendation: strong
  • Statement 3.3UEG/ESNM recognize that the yield of EGD for diagnosing structural abnormalities underlying esophageal dysphagia varies among studies. However, structural abnormalities are well visualized on EGD. Erosive reflux disease that can progress to peptic strictures and EoE, which can be associated with fibrotic narrowing of the esophagus, are common. Idiopathic fibrosis (Schatzki ring), complications of hiatus hernia, as well as malignancies, are less frequent.Level of evidence: low, grade of recommendation: strong
  • Statement 3.4UEG/ESNM suggest that esophageal biopsy sampling should be obtained in all patients with dysphagia, especially if clinical characteristics (male, young age, history of atopy or allergy) are suggestive for eosinophilic esophagitis even if macroscopic endoscopy results normal.Level of evidence: low, grade of recommendation: strong
  • Statement 3.5UEG/ESNM recognize that Edema, Rings, Exudates, Furrows and Stenosis are the most relevant endoscopic findings of EoE.Level of evidence: high, grade of recommendation: strong
  • Statement 3.6UEG/ESNM recommend the use of HRM in esophageal dysphagia as HRM is the most important technology focused on assessing esophageal motor function causing dysphagia in endoscopy‐negative dysphagia patients.Level of evidence: high, grade of recommendation: strong
  • Statement 3.7UEG/ESNM suggest the use of pH and impedance‐pH monitoring as it might provide information on the possible presence of GERD or esophageal hypersensitivity.Level of evidence: moderate, grade of recommendation: weak
  • Statement 3.8In patients with esophageal dysphagia, UEG/ESNM suggest a barium esophagram as complementary investigation to improve the diagnosis of structural and functional esophageal disease when endoscopy and HRM did not fully explain symptoms.Level of evidence: moderate, grade of recommendation: strong
  • Statement 3.9UEG/ESNM recommends the use of FLIP as an adjunctive diagnostic test in patients with dysphagia and inconclusive diagnoses from previous explorations including upper endoscopy and high‐resolution esophageal manometry.Level of evidence: moderate, grade of recommendation: strong
  • Statement 3.10UEG/ESNM recommend the use of imaging studies when no endoscopic abnormalities are found and when the results of esophageal motility studies are atypical or inconclusive.Level of evidence: moderate, grade of recommendation: strong
  • Statement 3.11UEG/ESNM do not recommend clinical swallow evaluation alone to definitely characterize OD.Level of evidence: high, grade of recommendation: strong
  • Statement 3.12UEG/ESNM indicate FEES for (1) symptoms and signs of OD (OD), (2) selecting optimal dietary conditions, (3) designing a patient‐tailored OD treatment plan, and (4) verifying treatment outcomes and disease progression. UEG/ESNM do not recommend FEES in patients with bilateral complete nasal obstruction, a respiratory rate > 35/min, impaired consciousness, or refusal of oral food administration. UEG/ESNM do not suggest FEES in patients with severe agitation, possible inability to cooperate, and acute risk of vasovagal episode and bradycardia.Level of evidence: moderate, grade of recommendation: weak
  • Statement 3.13UEG/ESNM recommend the use of VFSS, alongside FEES, as the method of choice for the instrumental assessment of oropharyngeal dysfunction. UEG/ESNM indicate the use of VFSS to assess structural and functional abnormalities of the oral preparatory, oral transit, pharyngeal and esophageal phases of swallowing and to determine treatment strategies to minimize aspiration risk and increase swallow efficiency. UEG/ESNM might consider the use of ultrasonograpy to evaluate muscles thickness and hyoid bone motion in patients with dysphagia, but the lack of standardized parameters limits its clinical utility.Level of evidence: for VFSS: high, for US: low; grade of recommendation: for VFSS: strong, for US: weak
  • Statement 3.14UEG/ESNM suggest the use of pharyngeal HRM in patients in whom the pharyngeal and UES function remains unclear and who present with abnormal swallow efficiency (residue) or safety (aspiration).Level of evidence: moderate, grade of recommendation: weak

Section 4: Therapeutic Approaches

  • Statement 4.1UEG/ESNM recognize that there is no clearly effective medical treatment able to improve motor function in patients with ineffective motility disorders. The management of these patients should be focused on treating the concomitant clinical scenario (e.g., GERD), rather than motor abnormalities.Level of evidence: very low; grade of recommendation: weak
  • Statement 4.2UEG/ESNM recognize that the medical management of esophageal hypercontractile motility or spasm requires a multifaceted approach. UEG/ESNM suggest the use of PPIs, calcium‐channel blockers, nitrates, phosphodiesterase type 5 inhibitors and incorporating other medications, such as antidepressants or peppermint oil, though endoscopic interventions may yield better outcomes in selected cases.Level of evidence: very low—grade of recommendation: weak
  • Statement 4.3UEG/ESNM suggest that botulin toxin injection might be considered in the management of hypercontractile esophageal motility disorders. POEM could be justified in patients with concomitant esophagogastric junction disorder. In this later population, balloon dilation may also be an effective treatment, but further evidence is needed.Level of evidence: very low—grade of recommendation: weak
  • Statement 4.4UEG/ESNM recognize that EGJOO often requires a tailored approach to management, with conservative management being the safest initial option. Structural EGJOO might considered to be treated with endoscopic or surgical interventions, while functional EGJOO might be considered for targeted therapy if symptoms are durable and worsening.Level of evidence: very‐low, GRADE of recommendation: weak
  • Statement 4.5UEG/ESNM recognize that in patients with functional dysphagia antidepressants or neuromodulators might be considered, but there is lack of data to recommend their use.Level of evidence: very‐low, GRADE of recommendation: weak
  • Statement 4.6UEG/ESNM recognize that in patients with functional dysphagia, there is lack of data to recommend the use of complementary or alternative therapies.Level of evidence: very‐low, GRADE of recommendation: weak
  • Statement 4.7UEG/ESNM consider the use of swallow therapy for OD to improve swallowing mechanics, reduce symptoms, and enhance quality of life. Swallow therapy could be more effective when using validated assessment tools, consistent treatment parameters, and considering long‐term follow‐up.Level of evidence: low—grade of recommendation: weak
  • Statement 4.8UEG/ESNM might consider surgical treatment for OD primarily based on the etiology. It is most appropriate for correcting anatomical abnormalities.Level of evidence: very‐low, grade of recommendation: weak
  • Statement 4.9In patients with post‐stroke dysphagia or due to other neurogenic diseases, UEG/ESNM suggest that treatment with neuromodulatory techniques should preferably be conducted within a clinical trial setting.

Abstract

Dysphagia is a prevalent symptom of the upper gastrointestinal tract causing health related consequences, impacting quality of life and is associated with global economic burden. Swallowing difficulties are classified into oropharyngeal dysphagia (OD) and esophageal dysphagia. Despite its clinical importance, dysphagia is associated with several uncertainties regarding its optimal diagnostic work‐up and management, particularly, considering the progress with diagnostic modalities and technologies. A Delphi consensus was performed with experts from various disciplines who conducted a literature summary and voting process on 41 statements. Quality of evidence was evaluated using the grading of recommendations, assessment, development, and evaluation criteria. Consensus was reached for all the statements. The panel agreed with the definition and prevalence of esophageal and OD types. The role of endoscopy, high‐resolution manometry, EndoFLIP, barium swallow and other imaging tests in evaluating esophageal dysphagia has reached overall strong agreement. Videofluoroscopic swallow study, alongside fiber‐endoscopic evaluation of swallowing, as the methods of choice for the instrumental assessment of oropharyngeal dysfunction is a strong recommendation. Regarding treatment, a weak recommendation was achieved for the use of PPIs, calcium‐channel blockers, nitrates, phosphodiesterase type 5 inhibitors, antidepressants or peppermint oil for the treatment of hypercontractile esophagus. A strong recommendation exists for endoscopic and surgical treatment of achalasia, while a weak recommendation is provided for other esophageal motility disorders. Regarding OD, a weak recommendation was achieved for swallow therapy, to improve swallowing mechanics, reduce symptoms, and enhance quality of life. Swallow therapy could be more effective when using validated assessment tools, consistent treatment parameters, and considering long‐term follow‐up. A multinational group of European experts summarized the current state of consensus on the definition, diagnosis, and management of dysphagia.

Contents of the original publication

The section headings of the original.

  • Introduction
  • Methods
  • Results
  • Section 1: Definition and Epidemiology
  • Section 2: Physiopathology and Related Conditions
  • Section 3: Diagnosis
  • Section 4: Therapeutic Approaches
  • Summary of Recommendation
  • Conclusion

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