Which doctor do I see about this eating problem?
June 20, 2019 5:56 PM Subscribe
I'm an otherwise healthy adult who's been having trouble eating for months now. I can't tell if this is due to a physical problem, stress/anxiety, or all of the above. I've had little luck with any doctors I've seen about it. I don't know how to fix this or what kind of doctor could likely help.
I am a 32 year old male, 153 lbs and 5'9". There are a lot of details below.
Some possibly-relevant background details: I have had occasional acid reflux, mainly low in my chest and usually coincident with stress, for most of my adult life. I used to wear braces, my retainer broke about 10 years ago, I never did anything about it and my teeth shifted some. I have always been a relatively slow eater, but I never felt like it was difficult to eat until this started happening.
My first symptom appeared about 15 months ago. Back then, every once in a while, I would encounter what medical googling seems to call "trouble initiating a swallow" -- I would have a mouthful of chewed food, my mouth would be all like "it's time to swallow" and my throat would say "huh?" That's really what it felt like, a total disconnection between two steps in a process that had been autonomous my whole life. Liquids were never a problem, and often helped food go down (although sometimes I had trouble swallowing my own saliva when I wasn't eating). Over time the problem became more consistent and reliable until it affected every meal. I discovered that if I cleared my throat, or sniffed, or shifted in my chair I would then be able to get the swallow process going. Food generally went down with no issue once it got started. I never made any headway with figuring out which foods or circumstances would make it change. I would have good days and bad days, it seemed.
Over the last two or three months, it seems to be getting worse. I've resorted to taking smaller bites, and it's taking me longer and longer to chew the food before I even attempt to swallow. The longer I eat the harder it tends to get. Often it feels like bits of food are stuck in my throat after the swallow is done. I clear my throat, sometimes try a cough or two, but it doesn't seem to dislodge anything. Last time I tried to eat a burrito, it took me 90 minutes -- practically all of that time was spent chewing. Recently I've had to give up on finishing a meal because of how long it was taking, either because it was getting awkward, or the food got cold and unappealing, or I had a particularly bad swallow and lost my appetite.
Aside from that, I have still have the occasional feeling of acid in different spots, usually after eating. I recently started getting it in my neck, in addition to my usual spot low in the left almost-center of my chest (roughly nipple height). Sometimes I can taste it.
Other potentially pertinent detail, last time I was at the dentist, she remarked "wow, you have a lot of saliva." Wow -- that was her actual word choice. I asked if it could be a part of this problem, she did not think so. My saliva does seem rather thick, and it never really used to be.
I don't have vomiting, or anything I would classify as pain. My actual digestion seems about the same as it's always been. I have not choked, but there are times where I wonder how close some bit of food actually got to my airway.
Lastly, my emotional state: I hate my job with a bitter burning passion, and even when I'm not at work my thoughts keep finding their way back to it. I am of the opinion that what we do is a pointless waste of time and human capital, and I believe I am burned out beyond hope, which is a whole other can of worms that I'd rather not get into. I can't presently ragequit or switch jobs unless I can match or exceed my current salary, which is a whole other-other can of worms that I'd rather not get into. Suffice it to say, I'm not all sunshine and lollipops these days.
Things I have tried:
- Saw a general physician for my annual check-up and told him my story. Result: Not his specialty, apparently. Nothing abnormal found during the physical or routine blood work. He referred me to an ENT for "oral phase dysphagia. "
- Saw the ENT. He asked me a bunch of questions, shoved a camera up my nose and looked as far as my vocal cords. Didn't see anything unusual, aside from evidence of post-nasal drip. He suggested it might be all in my head, but recommended a 30-day regimen of Prilosec OTC. Result: After taking the Prilosec, I did notice a reduction in the amount of acid events I felt, but it made no improvement in chewing, swallowing, or needing to clear my throat afterwards. After stopping Prilosec, the acid is back (but only occasionally, and not any worse than it had been).
- Spoke to the dentist via phone to ask if a problem with my bite could be the root cause. I have an upcoming appointment, but she suggested wearing a mouth guard at night in case I'm clenching or grinding my teeth in my sleep. Result: My jaw muscles seem less tired after a marathon chewing session, but no real change in any of the main symptoms.
My crackpot theories:
- Something is wrong with my bite. Maybe teeth aren't meshing, or they're hitting each other, or I'm having to contort my jaw in a way that prevents things from working how they should. Only real evidence that I have to support this is the fact that there are some fibrous/gristly/chewy bits I can't break down in my mouth and have to spit out, but nobody else at the table experiences it. Then again, it could be that I only notice these bits because I'm over-chewing (over-analyzing?) my food.
- Maybe there is something to the reflux idea. If chronic acid has irritated/damaged something in my throat, maybe 30 days of Prilosec isn't going to magically fix that. LPR? GERD?
- It's in my head. To this day I can't predict how hard it will be for me to eat a certain food. Maybe I've psyched myself out, or developed some kind of phobia related to eating. I have become rather concerned that I could choke one of these days (although to date I never have). I tend to have a worse time if there is difficult conversation happening, and like I said, there are good days and bad days.
- Something else?
Aside from my dentist appointment in about three weeks, I don't know what kind of doctor I should be talking to. General physician said "I don't know, see the ENT" and the ENT said "I don't see anything wrong and [in not such direct wording] I don't believe you." That's been very dispiriting for me, as has the whole "stand out like a weirdo every time you eat socially" thing.
TL;DR: Having a real bad time chewing and/or swallowing food. What sort of doctor handles that, and how do I get them to believe me?
I am a 32 year old male, 153 lbs and 5'9". There are a lot of details below.
Some possibly-relevant background details: I have had occasional acid reflux, mainly low in my chest and usually coincident with stress, for most of my adult life. I used to wear braces, my retainer broke about 10 years ago, I never did anything about it and my teeth shifted some. I have always been a relatively slow eater, but I never felt like it was difficult to eat until this started happening.
My first symptom appeared about 15 months ago. Back then, every once in a while, I would encounter what medical googling seems to call "trouble initiating a swallow" -- I would have a mouthful of chewed food, my mouth would be all like "it's time to swallow" and my throat would say "huh?" That's really what it felt like, a total disconnection between two steps in a process that had been autonomous my whole life. Liquids were never a problem, and often helped food go down (although sometimes I had trouble swallowing my own saliva when I wasn't eating). Over time the problem became more consistent and reliable until it affected every meal. I discovered that if I cleared my throat, or sniffed, or shifted in my chair I would then be able to get the swallow process going. Food generally went down with no issue once it got started. I never made any headway with figuring out which foods or circumstances would make it change. I would have good days and bad days, it seemed.
Over the last two or three months, it seems to be getting worse. I've resorted to taking smaller bites, and it's taking me longer and longer to chew the food before I even attempt to swallow. The longer I eat the harder it tends to get. Often it feels like bits of food are stuck in my throat after the swallow is done. I clear my throat, sometimes try a cough or two, but it doesn't seem to dislodge anything. Last time I tried to eat a burrito, it took me 90 minutes -- practically all of that time was spent chewing. Recently I've had to give up on finishing a meal because of how long it was taking, either because it was getting awkward, or the food got cold and unappealing, or I had a particularly bad swallow and lost my appetite.
Aside from that, I have still have the occasional feeling of acid in different spots, usually after eating. I recently started getting it in my neck, in addition to my usual spot low in the left almost-center of my chest (roughly nipple height). Sometimes I can taste it.
Other potentially pertinent detail, last time I was at the dentist, she remarked "wow, you have a lot of saliva." Wow -- that was her actual word choice. I asked if it could be a part of this problem, she did not think so. My saliva does seem rather thick, and it never really used to be.
I don't have vomiting, or anything I would classify as pain. My actual digestion seems about the same as it's always been. I have not choked, but there are times where I wonder how close some bit of food actually got to my airway.
Lastly, my emotional state: I hate my job with a bitter burning passion, and even when I'm not at work my thoughts keep finding their way back to it. I am of the opinion that what we do is a pointless waste of time and human capital, and I believe I am burned out beyond hope, which is a whole other can of worms that I'd rather not get into. I can't presently ragequit or switch jobs unless I can match or exceed my current salary, which is a whole other-other can of worms that I'd rather not get into. Suffice it to say, I'm not all sunshine and lollipops these days.
Things I have tried:
- Saw a general physician for my annual check-up and told him my story. Result: Not his specialty, apparently. Nothing abnormal found during the physical or routine blood work. He referred me to an ENT for "oral phase dysphagia. "
- Saw the ENT. He asked me a bunch of questions, shoved a camera up my nose and looked as far as my vocal cords. Didn't see anything unusual, aside from evidence of post-nasal drip. He suggested it might be all in my head, but recommended a 30-day regimen of Prilosec OTC. Result: After taking the Prilosec, I did notice a reduction in the amount of acid events I felt, but it made no improvement in chewing, swallowing, or needing to clear my throat afterwards. After stopping Prilosec, the acid is back (but only occasionally, and not any worse than it had been).
- Spoke to the dentist via phone to ask if a problem with my bite could be the root cause. I have an upcoming appointment, but she suggested wearing a mouth guard at night in case I'm clenching or grinding my teeth in my sleep. Result: My jaw muscles seem less tired after a marathon chewing session, but no real change in any of the main symptoms.
My crackpot theories:
- Something is wrong with my bite. Maybe teeth aren't meshing, or they're hitting each other, or I'm having to contort my jaw in a way that prevents things from working how they should. Only real evidence that I have to support this is the fact that there are some fibrous/gristly/chewy bits I can't break down in my mouth and have to spit out, but nobody else at the table experiences it. Then again, it could be that I only notice these bits because I'm over-chewing (over-analyzing?) my food.
- Maybe there is something to the reflux idea. If chronic acid has irritated/damaged something in my throat, maybe 30 days of Prilosec isn't going to magically fix that. LPR? GERD?
- It's in my head. To this day I can't predict how hard it will be for me to eat a certain food. Maybe I've psyched myself out, or developed some kind of phobia related to eating. I have become rather concerned that I could choke one of these days (although to date I never have). I tend to have a worse time if there is difficult conversation happening, and like I said, there are good days and bad days.
- Something else?
Aside from my dentist appointment in about three weeks, I don't know what kind of doctor I should be talking to. General physician said "I don't know, see the ENT" and the ENT said "I don't see anything wrong and [in not such direct wording] I don't believe you." That's been very dispiriting for me, as has the whole "stand out like a weirdo every time you eat socially" thing.
TL;DR: Having a real bad time chewing and/or swallowing food. What sort of doctor handles that, and how do I get them to believe me?
See a gastroenterologist for an endoscopy and imaging tests (barium) which will show how well you are swallowing.
posted by pushing paper and bottoming chairs at 6:43 PM on June 20, 2019 [1 favorite]
posted by pushing paper and bottoming chairs at 6:43 PM on June 20, 2019 [1 favorite]
You of course need to rule out anything physical. But I have had similar issues on and off for many years (I’m 43) and it’s always related to anxiety. I actually went through a phase in my 20s where I would chew a bite of food, spit it out, chew the next bite and spit it out and so on. Having to swallow a pill is a special kind of hell for me. But something about recognizing that it’s in my head seems to help during these bouts. Good luck.
posted by amro at 6:45 PM on June 20, 2019 [3 favorites]
posted by amro at 6:45 PM on June 20, 2019 [3 favorites]
It sounds like the OP had a scope.
I had a stricture in my esophagus caused by silent reflux (I didn’t know I had it, the heartburn wasn’t where I could feel it) and along with corrective actions for the reflux, a gastroenterologist stuck some kind of tube down my throat to stretch it back out. It was a sedated procedure. I had gone in because it felt like I had food caught in my throat that I couldn’t dislodge by swallowing and it was making me panicky. Just mentioning this because you said you had heartburn. But the scope you had done should have caught it.
posted by flannel at 6:48 PM on June 20, 2019
I had a stricture in my esophagus caused by silent reflux (I didn’t know I had it, the heartburn wasn’t where I could feel it) and along with corrective actions for the reflux, a gastroenterologist stuck some kind of tube down my throat to stretch it back out. It was a sedated procedure. I had gone in because it felt like I had food caught in my throat that I couldn’t dislodge by swallowing and it was making me panicky. Just mentioning this because you said you had heartburn. But the scope you had done should have caught it.
posted by flannel at 6:48 PM on June 20, 2019
The OP had what sounds like a laryngoscope but not a full endoscopy which is what a gastroenterologist could do.
Seconding the speech and language pathologist (“speech and swallow therapy”). You had me at “trouble initiating a swallow” - request an referral through your PCP.
posted by amy.g.dala at 6:54 PM on June 20, 2019 [3 favorites]
Seconding the speech and language pathologist (“speech and swallow therapy”). You had me at “trouble initiating a swallow” - request an referral through your PCP.
posted by amy.g.dala at 6:54 PM on June 20, 2019 [3 favorites]
Yeah, you need to see a gastroenterologist for an endoscopy. I don’t know where you’re located, but if you need a name in NYC, feel free to MeMail me; my guy is great.
posted by holborne at 7:03 PM on June 20, 2019
posted by holborne at 7:03 PM on June 20, 2019
Maybe a Schatzki ring? See a gastroenterologist.
posted by Grumpy old geek at 7:19 PM on June 20, 2019
posted by Grumpy old geek at 7:19 PM on June 20, 2019
Nthing swallow study.
posted by tafetta, darling! at 7:40 PM on June 20, 2019
posted by tafetta, darling! at 7:40 PM on June 20, 2019
I agree with amro, you need to rule out physical issues, but I have a good friend who had a very similar issue that was definitely anxiety-related. She had great (and quick!) success getting past the eating/swallowing issue with EMDR therapy.
posted by mjcon at 7:45 PM on June 20, 2019
posted by mjcon at 7:45 PM on June 20, 2019
GI for a scope and swallow study and treatment for the reflux. If you need speech therapy for swallowing, they'd refer you. Don't start with speech therapy; you need some GI tests first.
How is your weight? It sounds like you're having trouble finishing meals, which could cause some weight loss, but if you are having sudden or otherwise unexplainable weight loss, be sure to mention this to your doctor as well. It could be a sign of something more serious.
posted by peanut_mcgillicuty at 7:46 PM on June 20, 2019
How is your weight? It sounds like you're having trouble finishing meals, which could cause some weight loss, but if you are having sudden or otherwise unexplainable weight loss, be sure to mention this to your doctor as well. It could be a sign of something more serious.
posted by peanut_mcgillicuty at 7:46 PM on June 20, 2019
I'm an emergency physician/medical toxicologist.
1. The medical term for trouble initiating a swallow is oropharyngeal dysphagia (or-oh-fuh-RINN-djee-ull dis-FAY-djuh). I mention it only because it's the (search) term you should use if you're interested in exploring scientific/clinical research on the subject.
2. internet fraud detective squad, station number 9: This is for a gastroenterologist. Sounds like esophageal issues are a possibility. You need a scope.
This is the only reply so far you should pay any attention to, but only the first part really. A GI specialist is 100%, hands down who you should see first (or next, depending on how you look at it).
But swallowing disorders originating in the esophagus don't really cause trouble initiating a swallow. Instead, they cause a sensation of food being stuck in the area between the suprasternal notch and the xiphoid process.
posted by BadgerDoctor at 8:22 PM on June 20, 2019 [7 favorites]
1. The medical term for trouble initiating a swallow is oropharyngeal dysphagia (or-oh-fuh-RINN-djee-ull dis-FAY-djuh). I mention it only because it's the (search) term you should use if you're interested in exploring scientific/clinical research on the subject.
2. internet fraud detective squad, station number 9: This is for a gastroenterologist. Sounds like esophageal issues are a possibility. You need a scope.
This is the only reply so far you should pay any attention to, but only the first part really. A GI specialist is 100%, hands down who you should see first (or next, depending on how you look at it).
But swallowing disorders originating in the esophagus don't really cause trouble initiating a swallow. Instead, they cause a sensation of food being stuck in the area between the suprasternal notch and the xiphoid process.
posted by BadgerDoctor at 8:22 PM on June 20, 2019 [7 favorites]
I am in no way qualified to answer your question.
However, I've known people who had trouble swallowing with the underlying cause being neurological. I don't know if it's the same kind of trouble swallowing you have. Nor do I know what specific neurological thing was the cause. I also don't know if they had other symptoms beyond eating-related (i.e. maybe they did and if you don't it's not neurological. ) But if the GI specialist doesn't pan out, consider trying a neurologist.
posted by If only I had a penguin... at 8:29 PM on June 20, 2019 [1 favorite]
However, I've known people who had trouble swallowing with the underlying cause being neurological. I don't know if it's the same kind of trouble swallowing you have. Nor do I know what specific neurological thing was the cause. I also don't know if they had other symptoms beyond eating-related (i.e. maybe they did and if you don't it's not neurological. ) But if the GI specialist doesn't pan out, consider trying a neurologist.
posted by If only I had a penguin... at 8:29 PM on June 20, 2019 [1 favorite]
You can have an infection in your stomach that will give you acid reflux feeling problems. You do need a swallow study, and a new job, with medical benefits. You might want to see a neurologist.
posted by Oyéah at 8:52 PM on June 20, 2019
posted by Oyéah at 8:52 PM on June 20, 2019
Not a doctor. I heard about someone having symptoms similar to what you described for them it turned out to be achalasia (secondary to a virus, it was thought). A surgical procedure was done and they're ok now, but they did have a very hard time for several months. A gastroenterologist at a teaching hospital figured it out.
posted by cotton dress sock at 9:00 PM on June 20, 2019
posted by cotton dress sock at 9:00 PM on June 20, 2019
Came in to say GI, scope for EoE (and other esophageal issues).
posted by bananacabana at 9:07 PM on June 20, 2019
posted by bananacabana at 9:07 PM on June 20, 2019
Get your esophagus scoped ASAP. Difficulty swallowing can be one of the symptoms of esophageal cancer.
posted by monotreme at 11:58 PM on June 20, 2019 [1 favorite]
posted by monotreme at 11:58 PM on June 20, 2019 [1 favorite]
I just want to say in response to monotreme's reply that this does not sound at all like the symptoms of oesophageal cancer so please don't panic it is that. My father had it, he never had problems with the swallowing action, from chewing to getting the food from the mouth to the throat.
On the other hand, I certainly did have problems with swallowing and frightening feelings in my chest/oesophagus after my dad's diagnosis, due to the fear and stress of it all. I'm quite an anxious person! Seeing as you are having issues with work related unhappiness it might help you to access some counselling or therapy if you can, while you're exploring any further medical tests.
posted by tinwhiskers at 12:39 AM on June 21, 2019
On the other hand, I certainly did have problems with swallowing and frightening feelings in my chest/oesophagus after my dad's diagnosis, due to the fear and stress of it all. I'm quite an anxious person! Seeing as you are having issues with work related unhappiness it might help you to access some counselling or therapy if you can, while you're exploring any further medical tests.
posted by tinwhiskers at 12:39 AM on June 21, 2019
I'm a speech therapist specialising in swallowing (in the UK so things may work a little differently). I would be very uneasy seeing you before you had seen GI and had a scope down your oesophagus.
Very frequently that comes back normal and a CT of the neck and thorax also comes back normal. We know ENT think your pharynx and larynx are normal. At this point I would want a videofluoroscopy/modified barium swallow study, which is an x-ray video of you swallowing food and drink. Ideally covering oesophagus as well as oropharynx since oesophageal problems often are not diagnosed on a standard barium swallow using only liquid.
There are many, many things that could be causing your symptoms. Reflux is certainly a possible candidate. Anxiety about swallowing is probably also contributing, but it can be secondary to the actual problem or the primary cause. Whichever it is, it isn't all in your head! It is a real physical symptom that can be treated physically as well as addressing the anxiety.
People above commented that this doesn't sound oesophageal because of the difficulty initiating the swallow. Research says that actually there is a very high degree of overlap - an oesophageal cause very frequently impacts on the function of the pharyngeal stage. Equally if you know swallowing is going to be a problem then of course your oral stage won't be smooth and short. If you are hesitating before stepping off a high ledge (despite ropes or zip wire) does that mean you have a problem walking? Or do you end up spending ages making sure your harness is on, everything is attached and you are mentally ready?
I wouldn't expect a 30 day course of PPIs to fix damage from LPR, though might expect it to improve. Our ENTs tend to prescribe 6-8 weeks of omeprazole twice a day plus an alginate (Gaviscon Advance or equivalent) four times a day plus lifestyle changes. We also tell people not to expect change for 4-6 weeks, though that is mainly taking about delicate vocal cords and voice.
Good luck. Lots to unpack. Start with GI.
posted by kadia_a at 5:27 AM on June 21, 2019 [8 favorites]
Very frequently that comes back normal and a CT of the neck and thorax also comes back normal. We know ENT think your pharynx and larynx are normal. At this point I would want a videofluoroscopy/modified barium swallow study, which is an x-ray video of you swallowing food and drink. Ideally covering oesophagus as well as oropharynx since oesophageal problems often are not diagnosed on a standard barium swallow using only liquid.
There are many, many things that could be causing your symptoms. Reflux is certainly a possible candidate. Anxiety about swallowing is probably also contributing, but it can be secondary to the actual problem or the primary cause. Whichever it is, it isn't all in your head! It is a real physical symptom that can be treated physically as well as addressing the anxiety.
People above commented that this doesn't sound oesophageal because of the difficulty initiating the swallow. Research says that actually there is a very high degree of overlap - an oesophageal cause very frequently impacts on the function of the pharyngeal stage. Equally if you know swallowing is going to be a problem then of course your oral stage won't be smooth and short. If you are hesitating before stepping off a high ledge (despite ropes or zip wire) does that mean you have a problem walking? Or do you end up spending ages making sure your harness is on, everything is attached and you are mentally ready?
I wouldn't expect a 30 day course of PPIs to fix damage from LPR, though might expect it to improve. Our ENTs tend to prescribe 6-8 weeks of omeprazole twice a day plus an alginate (Gaviscon Advance or equivalent) four times a day plus lifestyle changes. We also tell people not to expect change for 4-6 weeks, though that is mainly taking about delicate vocal cords and voice.
Good luck. Lots to unpack. Start with GI.
posted by kadia_a at 5:27 AM on June 21, 2019 [8 favorites]
Trouble swallowing was a symptom of thyroid disease for me. It sounds like you have more going on than that, but if it hasn't been checked out (simple blood test), you may want to request that as well.
posted by dog-eared paperback at 8:08 AM on June 21, 2019
posted by dog-eared paperback at 8:08 AM on June 21, 2019
My sister in law was diagnosed with eosinophilic esophagitis a couple years ago and these sound a lot like her symptoms.
posted by gaspode at 1:26 PM on June 21, 2019
posted by gaspode at 1:26 PM on June 21, 2019
Not that kind of a doctor, but after a lifetime of choking more than anyone else I knew and having weird, ropey saliva, I was diagnosed with eosinophilic esophagitis. Endoscopy time!
posted by athirstforsalt at 2:46 AM on June 23, 2019
posted by athirstforsalt at 2:46 AM on June 23, 2019
This thread is closed to new comments.
posted by little mouth at 6:02 PM on June 20, 2019 [14 favorites]