Single Best Answer (SBA) · Dysphagia and Oesophageal Cancer
A 67-year-old man describes dysphagia that began with solids and has progressed over 3 months to include soft foods, with marked weight loss. He is a lifelong smoker and betel chewer. What is the most likely diagnosis?
Show answer and explanation
Answer: C. Carcinoma of the oesophagus
Progressive dysphagia for solids in the elderly
The single most important rule in dysphagia is that progressive dysphagia for solids in an elderly patient is oesophageal carcinoma until proven otherwise. Missing a malignancy here is disastrous.
Why carcinoma
- Mechanical obstruction classically causes dysphagia that begins with solids and progresses to liquids as the lumen narrows.
- Red flags here: age, progressive course, marked weight loss, and risk factors (smoking, betel, alcohol).
Mechanical vs neuromuscular dysphagia
| Feature | Mechanical (e.g. cancer) | Neuromuscular (e.g. achalasia) |
|---|---|---|
| Onset | Insidious, progressive | Insidious, intermittent |
| Sequence | Solids then liquids | Liquids and solids together (or liquids worse) |
| Weight loss | Common, marked | Late |
Aetiology of squamous carcinoma
- Preventable: smoking, betel/areca, alcohol.
- Others: achalasia, corrosive strictures, tylosis (palmoplantar keratosis), Plummer-Vinson web.
Next step
Upper GI endoscopy with biopsy is the key investigation - it visualises the lumen and wall, allows biopsy of all lesions, and offers therapeutic options.
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