When the swallow stalls: understanding oesophageal DGBIs

When the swallow stalls: understanding oesophageal DGBIs

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Abstract

Have you ever felt a piece of food was stuck in your throat, even though endoscopy was completely clear? Or do you struggle with severe, crushing chest pain that your cardiologist swears is not your heart? Welcome to the world of oesophageal Disorders of Gut-Brain Interaction (DGBIs) - a category defined by the updated Rome V criteria, where symptoms arise from disturbed brain-oesophagus signalling rather than structural disease [1, 2].

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The brain-oesophagus disconnect

For a long time, persistent throat and chest symptoms were dismissed if standard imaging did not show inflammation, acid damage or blockage. The Rome V framework reminds us that the oesophagus is heavily innervated by the nervous system [1]. When signalling between the brain and the nerves in the food pipe is "hyper-tuned", normal sensations are amplified or perceived as painful [2].

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Key disorders in this category

• Functional heartburn: Burning discomfort behind the breastbone that resembles reflux but does not respond sufficiently to acid-suppressing treatment with a proton pump inhibitor (PPI). The diagnosis requires that gastroscopy shows no inflammation or other mucosal injury in the oesophagus, and that ambulatory pH or pH-impedance monitoring shows normal acid exposure with no association between symptoms and reflux episodes. Acid measurement and mucosal injury are two different things: measuring acid exposure tells you how much acid comes up, while mucosal injury is seen at gastroscopy and on biopsy [2].
• Reflux hypersensitivity: Normal, everyday amounts of stomach acid reach the oesophagus. While it would not bother most people, a hypersensitive gut-brain axis perceives it as a severe burn [2].
• Globus: The frustrating, continuous feeling of a lump or "ball" in the throat, often briefly relieved by eating [1, 2].
• Functional chest pain: Unexplained, often severe chest pain not caused by cardiac disease, reflux or oesophageal motility spasms [2].

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Work-up

Diagnosis is positive - based on the symptom pattern as defined by Rome V - but requires that structural and acid-related disease has been excluded [1]. This typically involves an oral gastroscopy, sometimes supplemented with manometry [2]. See also swallowing difficulties and GERD / acid reflux.

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Takeaway and treatment

If acid reducers are not touching your chest or throat symptoms, the root cause may not be chemical or structural - it may be a hypersensitive neural pathway [2]. Treatments such as low-dose neuromodulators (for example low-dose tricyclic antidepressants) or gut-directed behavioural therapy can effectively "turn down the volume" on the signals [1, 2].

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Work-up at Kirurgen.dk

We assess oesophageal and gastric symptoms with oral gastroscopy, nasal gastroscopy and Barrett's oesophagus screening.

The rest of the DGBI series:

• Gastroduodenal DGBIs (coming soon)
• Bowel DGBIs (coming soon)
• Centrally mediated abdominal pain (coming soon)

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References

1. Corsetti M, Shin A, Lacy BE, Cash BD, Simrén M, et al. Bowel Disorders. Gastroenterology 2026;170(6):1261-1282. DOI: 10.1053/j.gastro.2026.02.003. PubMed - verified Rome V source document. The chapter is the Rome V text on bowel disorders and is used here as documentation of the Rome V framework itself. The domain-specific criteria are in reference 2.
2. Aziz Q, Fass R, Gyawali CP et al. Oesophageal Disorders. Rome IV/V chapter on functional heartburn, reflux hypersensitivity, globus and functional chest pain. Gastroenterology - consensus article.