Key points
- When food gets stuck when swallowing in a younger adult, the commonest cause is eosinophilic oesophagitis.2
- It is a chronic allergic inflammation of the oesophagus, and it has become steadily more common over recent decades.4
- It can only be diagnosed with a gastroscopy and biopsies, even if the oesophagus looks normal.1
- There are several effective treatments: high-dose omeprazole, orodispersible budesonide, elimination diets and biological drugs.3,6,7
- The longer diagnosis is delayed, the higher the risk of the oesophagus narrowing.5
This article summarises the evidence and clinical guidelines so you can understand your situation. It does not replace an individual assessment.
If food gets stuck when you swallow, especially meat or bread, and you have learned to eat slowly with plenty of water to avoid it, this article is for you. In younger adults, the commonest cause of this symptom is eosinophilic oesophagitis, a condition that is mistaken for reflux for years.
Difficulty swallowing rarely arrives in clinic as such. It arrives disguised as habits: chewing far more than normal, washing every mouthful down with water, leaving meat on the plate, always being the last to finish. These adaptations set in so gradually that they stop being seen as a problem, and that is why diagnosis is delayed for years.
What eosinophilic oesophagitis is
It is a chronic inflammatory disease of the oesophagus with an allergic basis. A type of white blood cell, the eosinophil, builds up in the oesophageal wall and maintains inflammation that, over the years, stiffens it and narrows the passage.2
It is now the leading cause of difficulty swallowing solids and of food impaction in younger adults, and is more common in men and in people with asthma, rhinitis, atopic dermatitis or food allergies.2
Why it is mistaken for reflux
The symptoms overlap and many patients are given acid-suppressing drugs for years. The difference is that the main problem here is not acid but allergic inflammation. And it can only be seen by taking biopsies.
Signs that point to this diagnosis
- A feeling that food stops in the chest, especially meat, bread or rice
- Episodes of choking on food, some requiring a visit to A&E to remove it
- Needing to drink a lot of water or chew a great deal in order to swallow
- Always being the last to finish a meal, or avoiding certain foods without having consciously decided to
- Heartburn or chest pain that does not improve with omeprazole
- A personal or family history of asthma, rhinitis, eczema or food allergies
How it is diagnosed
There is only one way: a gastroscopy with biopsies of the oesophagus. Guidelines recommend taking at least six biopsies from different levels, because the inflammation is patchy. The diagnosis is confirmed when 15 or more eosinophils per high-power field are counted and other causes have been ruled out.1,3
Here is the critical point: in some patients the oesophagus looks normal during endoscopy. If biopsies are not taken, the diagnosis is missed and the patient leaves with a report saying everything is fine.1,2
| What may be seen at gastroscopy | What it means |
|---|---|
| Longitudinal furrows | Active inflammation of the wall |
| Concentric rings (“ringed oesophagus”) | Fibrosis setting in |
| White plaques or spots | Clusters of eosinophils |
| Stricture (narrowing) | Advanced fibrosis; may need dilatation |
| Normal-looking oesophagus | Does not rule out the disease: biopsies are still needed |
Treatment works
There are several effective options, and the choice depends on your situation and preferences, not on a fixed rule.2,3
| Treatment | How it works | Points to consider |
|---|---|---|
| High-dose omeprazole or another PPI | Reduces inflammation as well as acid | Simple; roughly half of patients respond |
| Orodispersible budesonide | A steroid that acts in the oesophagus and is barely absorbed | In the pivotal trial, 58% were in remission at 6 weeks, compared with 0% on placebo6 |
| Elimination diet | Removes the foods that trigger inflammation (milk and wheat are the commonest) | Avoids drugs, but requires endoscopies to identify the responsible food |
| Dupilumab (biological) | Blocks a pathway of allergic inflammation | For cases that do not respond; in its trial about 60% achieved histological remission compared with 5% on placebo7 |
| Endoscopic dilatation | Widens an oesophagus that has already narrowed | Relieves difficulty swallowing but does not treat the inflammation |
Skin or blood allergy tests are no use for choosing which foods to remove, because they do not predict which ones cause inflammation in the oesophagus.2
Feeling better is not the same as being cured
Whatever the approach, the response must be checked with a repeat endoscopy and biopsies, usually after 8-12 weeks. Feeling better does not mean the inflammation has gone, and it is that inflammation that narrows the oesophagus in the long term.3
After diagnosis: maintenance
This is a chronic disease. When treatment is stopped, inflammation and symptoms usually return within weeks or months, and with them the long-term risk of strictures. That is why guidelines recommend continuing the treatment that worked, at the lowest effective dose.2,3
- Regular reviews to adjust treatment according to symptoms and, when needed, new biopsies.
- If diet was the treatment, the identified food stays out and the others are reintroduced.
- If there is narrowing, dilatation can be repeated when needed, always alongside treatment of the inflammation.
- Meanwhile, at meals: chew well, avoid large pieces of dry meat or hard bread and do not eat in a hurry.
Why it is worth not letting it slide
This is a disease with years of average delay between the first symptom and diagnosis, and with a treatment that works well when it is used. That combination is what makes the delay so regrettable.
A Swiss study showed that the proportion of patients with strictures rose from 17% when diagnosis was made within two years to 71% when it was delayed by more than twenty.5 The sooner inflammation is controlled, the less likely you are to end up with a narrowed oesophagus needing repeated dilatations.
Common myths
“It is reflux.”
The symptoms are similar, but the cause is allergic inflammation. If acid suppressants do not resolve difficulty swallowing, it needs looking for.2
“I had a normal gastroscopy, so there is nothing wrong.”
The oesophagus can look normal. Without biopsies it cannot be ruled out.1
“Allergy tests will tell me which foods to cut out.”
Standard allergy tests do not predict which foods inflame the oesophagus, and guidelines do not recommend using them to design the diet.2
“If I feel well, it is cured.”
Symptoms do not reflect inflammation well. The response is checked with biopsies.3
“It is a children’s disease.”
It affects children and adults, and in younger adults it is the leading cause of food impaction.2
“Drinking water to help swallow is normal.”
Needing water with every mouthful is a typical adaptation to the disease, not a harmless habit.
Warning signs: do not wait
Go to A&E if…
A food impaction that does not clear is an emergency: endoscopic removal should be done within a few hours.
- Food is stuck and will not go down, especially if you cannot even swallow your saliva
- You have severe chest pain or fever after choking on food
- You also find it hard to swallow liquids
See a doctor without delay, even if it is not urgent, if difficulty swallowing is getting worse, you are losing weight, or you are over 50 and the symptom is new: in that case other causes must be ruled out.
How I approach it in clinic
I ask about adaptations at mealtimes, because they give the clue: how long you take to eat, whether you need water, which foods you avoid and whether you have had any episode of impaction. I also ask about allergies and asthma.
If the suspicion is confirmed, I perform a gastroscopy under sedation, taking at least six biopsies. With the diagnosis, we choose together the treatment that best fits your life, and book a follow-up endoscopy to check that the inflammation has cleared. Then we discuss maintenance, because this is a chronic disease.
Do you recognise the pattern of eating slowly, constantly drinking water or avoiding certain foods?
It is worth investigating: diagnosis is straightforward and treatment works.
Frequently asked questions
Can eosinophilic oesophagitis be cured?
It is a chronic disease, but it can be well controlled. With treatment, most patients eat normally. If treatment is stopped, the inflammation usually returns.3
Will I have to stop eating certain foods?
Only if you choose diet as your treatment, and always guided by endoscopy. With drug treatments it is not necessary.2
What is the link with asthma and allergies?
They share the same type of allergic inflammation. Many people with eosinophilic oesophagitis have or have had asthma, rhinitis or eczema.2
Will I need regular gastroscopies?
Yes, at least one to check the response to treatment. After that, how often depends on how things go.3
What should I do if food gets stuck?
If it does not go down within a short time, especially if you cannot swallow your saliva, go to A&E. Do not try to make yourself sick or push it down with more food.
References
- Dellon ES, et al. Updated international consensus diagnostic criteria for eosinophilic esophagitis: proceedings of the AGREE conference. Gastroenterology. 2018. PubMed
- Lucendo AJ, et al. Guidelines on eosinophilic esophagitis: evidence-based statements and recommendations for diagnosis and management in children and adults. United European Gastroenterol J. 2017. PubMed
- Dellon ES, et al. ACG Clinical Guideline: Diagnosis and management of eosinophilic esophagitis. Am J Gastroenterol. 2025. Publication
- Navarro P, et al. Systematic review with meta-analysis: the growing incidence and prevalence of eosinophilic oesophagitis in children and adults in population-based studies. Aliment Pharmacol Ther. 2019. PubMed
- Schoepfer AM, et al. Delay in diagnosis of eosinophilic esophagitis increases risk for stricture formation in a time-dependent manner. Gastroenterology. 2013. PubMed
- Lucendo AJ, et al. Efficacy of budesonide orodispersible tablets as induction therapy for eosinophilic esophagitis in a randomized placebo-controlled trial. Gastroenterology. 2019. PubMed
- Dellon ES, et al. Dupilumab in adults and adolescents with eosinophilic esophagitis. N Engl J Med. 2022. PubMed
Links go to PubMed or the original publication and open in a new tab.
Related reading
Dr Fernando Casals Seoane
Consultant gastroenterologist with a PhD in Medicine from the Autonomous University of Madrid. He has worked at La Princesa University Hospital since 2009 and sees private patients at Ruber Juan Bravo Hospital. Certified by the European Board of Gastroenterology and Hepatology and honorary lecturer at the UAM. Principal investigator in international clinical trials on acute pancreatitis, including WATERFALL (NEJM, 2022).
Transparency: this article is not sponsored and does not promote any product or brand. All sources are linked.