Oesophagal cancer presented with Dysphagia

To be honest I really like surgical posting so far. Because when I was in BMS, (basic medical sciences) ,we were not really exposed to O&G cases in our problem-based learning (PBL). So when i was first posted in O&G department in my clinical years, I was like WHAAAATTTHAAAA...But it was fun, ikhlas. Hik2.

Different with the current posting, we were given few cases which can be found in surgical ward, colorectal cancer, oesophagal cancer, intestinal obstruction,[list goes on and on]. So it is really exciting to be able to clerk a real patient with real findings which was taught before in theory classes, which you usually can only see in books. But, it is not like that all the time, clinical judgement might varies... and very individual basis. Not all said symptoms will be there for a particular disease, hence diagnosis making really make my anxiety go through the rooftop during case presentation with fierce specialist.

Here is a case of oesophagal cancer! :)

*express consent was gained for educational purpose, might be altered and not completed to avoid breaching the confidentiality* 

History ( Somewhat the summary)

Madam X, a 50 y/o lady with no known underlying disease admitted to the ward due to difficulty in swallowing over 3 months.


She was apparently well until last 3 months when she started to experience difficulty in swallowing rice or chicken. Later, she began to have difficulty in swallowing semisolid food namely porridge. Very recently he began to have choking sensation upon swallowing. It was associated with vomiting shortly after eating. The vomiting was not projectile and not associated with nausea, abdominal pain, and headache. Vomitus was undigested foods with fluid with no blood or bile.

She began to have pain upon swallowing last 2 months which occur the food reach at the level of 3rd rib.The pain doesn't radiate elsewhere and limited during swallowing only, making it difficult tolerate oral intake or swallowing saliva. Pain score was 5-6/10.
Recently, she complained of passing out coal-black and sticky stool.

She denied having lower retrosternal pain, regurgutation, haematemesis, abdominal swelling, jaundice or fever, hoarseness of voice, hiccups.
She claimed to have lost of appetite and lost of weight about  20kg over a period of 3 months. There was no sign and symptoms of metastases. ( I will explore on this later in another post).
She was once went to a clinic due to the persisting condition last 3 weeksand was given medication but was unsure what was the prescription but she claimed the symptoms did not resolved.


She was a chronic tobacco smoker since teenager and stopped 3 months ago. She claimed that she did consume betelnut (sireh, a risk for nasopharyngeal ca as well), but denied consuming alcohol.

Discussion on dysphagia

Dysphagia should not be confussed with globus pharyngeus( lump in throat sensation)


The characteristic sof dysphagia should be detailed on further questioning, which is not only important to look for causative pathology but also crucial for the decision of managemenht whether the patient might need immedieate admission, treated as outpatient, TCA or considered as medical emergency especially inability to swallow saliva ( mati tercekik air liur, kau nak jadi gitu??)

 Causes, (find out yourself)

1. oesophagal motility such as achalasia (is a failure of smooth muscle fibers to relax, which can cause a sphincter to remain closed and fail to open when needed). Last time I tagged a surgery consultant in a hospital at surgical out patient. There was 16 y/o girl was diagnosed with achalasia, bringing along oesophagometry result with her. The consultant suggested her several treatment which includes fundoplication, cardiomyomectomy, because long term effect would be fatal.

2. extrinsic pressure may include mediastanal gland, goitre, enlarged left atrium


3. intrinsic lesion like malignancy, stricture

4. disease on mouth and tongue, difficult to initiate swallowing, lead to drooling

5. foreign body

Clinical Manifestation of Oesophagal cancer

1. early stage

• dysphagia ( most common), should be progressive
• weight loss in more than 50% of people with esophagal ca.

2. cancer progress

• bleeding, haematemesis, or malena
• hoarseness of voice caused by invasion of recurrent laryngeal nerve or compression onto it, making resection less possible
• pain may be felt in epigastric or retrosternal area. Pain on bony structures indicates metastatic disease
• persistent cough
• respratory sysytem : like shortness of breath (SOB) can be due to aspiration of undigested food or by direct invasion of tracheobronchial tree by tumour

3. Late stage

• may completely block the esophagus
• swallowing becomes impossible, regurgitaion and drooling as secretion build up in the mouth

Two types with different risk factors

1. squamous cell carcinoma

2. adenocarcinoma ( may occur in longstanding GERD and Barret esophagus)

References : 

1. crash course surgery

2.Merck Manual

3. medscape

Refer burkitt and talley for proper reading.