Progressive Dysphagia – PLAB/UKMLA Clinical Scenario (Suspected Oesophageal Cancer)
From August 2024 onwards, the PLAB 1 exam will be based on the MLA content map as part of the GMC’s new licensing assessment. However, core clinical concepts remain equally crucial for PLAB 1 preparation and UKMLA exam. This progressive dysphagia case is a classic high-yield scenario often seen in PLAB 1 exam questions and UKMLA exam questions, focusing on upper GI cancer red flags and NICE guideline-based management.
Clinical Scenario
A 55-year-old man presents to his GP with a 4-month history of progressive dysphagia. Initially, he had difficulty swallowing solid foods; now he struggles with liquids as well. He has unintentionally lost ~6 kg during this period. He denies any chronic heartburn, acid reflux, or odynophagia. He is a long-term smoker and rarely drinks alcohol. Physical exam is unremarkable aside from a modest weight loss and no palpable lymph nodes.
What is the most appropriate next step in management for this patient?
A. Barium swallow (esophagram)
B. Contrast-enhanced CT scan of chest and abdomen
C. Urgent upper gastrointestinal endoscopy (OGD)
D. Esophageal manometry
E. Trial of high-dose proton pump inhibitor (PPI) for 4 weeks
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Clinical Reasoning
This patient’s profile – a middle-aged man with progressive dysphagia (difficulty swallowing that started with solids and advanced to liquids) accompanied by significant weight loss – raises a high suspicion for oesophageal cancer en.wikipedia.org. Progressive dysphagia that first affects solids and later liquids typically indicates a mechanical obstruction (as opposed to a motility disorder) in the oesophagus , en.wikipedia.org, ncbi.nlm.nih.gov. In an exam context, dysphagia plus weight loss are red-flag symptoms for an upper GI malignancy until proven otherwise. The absence of chronic reflux symptoms (and thus no history of Barrett’s oesophagus) and the patient’s smoking habit further points towards oesophageal carcinoma (with smoking being a risk factor, particularly for squamous cell carcinoma).
Differential diagnosis: A benign peptic stricture from long-standing GERD could cause slowly progressive solid-food dysphagia, but it usually occurs in the context of chronic heartburn (which he denies) and often not accompanied by rapid weight loss. Achalasia, a motility disorder, classically causes dysphagia to both liquids and solids from the outset, rather than solids progressing to liquids; it can cause weight loss, but the pattern here (solids → liquids) is more suggestive of a structural lesion en.wikipedia.orgen.wikipedia.org. Given the alarm features (progression and weight loss), we must assume a malignant obstruction until proven otherwise.
Guideline-based approach: According to NICE suspected cancer referral guidelines, any patient of any age with dysphagia should be referred for an urgent upper GI endoscopy within 2 weeks nice.org.uk. Additionally, adults over 55 with weight loss and another alarm symptom (such as upper abdominal pain, reflux, or dyspepsia) also warrant urgent investigation nice.org.uk. In this case, the patient meets criteria by virtue of dysphagia alone (and he is >55 with weight loss, another red flag). An endoscopy (esophagogastroduodenoscopy) will directly visualise the oesophageal lumen and allow biopsy of any suspicious lesion, which is essential for confirming a diagnosis of cancer. This “straight-to-test” approach is crucial because it can expedite diagnosis of oesophageal cancer and improve outcomes nice.org.uk
By contrast, empirical treatment or delays in investigation could miss a narrow window for early diagnosis. For instance, simply prescribing a PPI in hopes of an ulcer or reflux aetiology would be inappropriate given the high likelihood of malignancy. Similarly, while imaging like CT can help stage a known cancer, it cannot definitively diagnose oesophageal cancer – tissue biopsy is needed. Therefore, the best next step is to promptly perform an upper GI endoscopy to evaluate and biopsy the lesion.
Recognising these red flags and knowing the recommended first-line investigation is vital for anyone preparing for the PLAB 1 or UKMLA exams. In exam scenarios, urgent endoscopy is the correct response to unexplained dysphagia because it aligns with the two-week cancer referral pathway. Other tests or treatments, if chosen first, would delay diagnosis or fail to address the core issue.
Accordingly, the clinical priority is clear: identify the cause of this patient’s dysphagia by direct visualisation. This brings us to the correct answer.
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Answer and Explanation ✅
The correct answer is C. Urgent upper gastrointestinal endoscopy (OGD). This is the most appropriate next step to investigate progressive dysphagia with suspected oesophageal cancer.
Urgent Upper GI Endoscopy (OGD) – First-line Investigation: Endoscopy is the gold-standard initial investigation for dysphagia with alarm features. It allows direct visualisation of the oesophagus, stomach, and duodenum, and crucially enables biopsy of any suspicious lesions. NICE guidelines mandate an urgent endoscopy (within 2 weeks) for patients with dysphagia to promptly diagnose or rule out oesophageal cancer nice.org.uk. In this patient, an OGD can confirm if a stricture or mass is present in the oesophagus, causing the obstruction. If a tumour is found, biopsies will establish the diagnosis (e.g. squamous cell carcinoma vs. adenocarcinoma) and guide further management. Early endoscopy is not only diagnostic but can be therapeutic as well (for example, dilating a stricture or stenting a malignant lesion if needed). In the context of the PLAB 1/UKMLA, choosing endoscopy reflects awareness of the “two-week rule” for suspected cancer – a key exam point. By performing an urgent endoscopy, we adhere to guidelines, avoid delay in diagnosis, and give the patient the best chance at timely treatment. This makes option C the correct answer.
Why Other Options are Less Suitable:
A. Barium swallow (esophagram): A barium swallow X-ray can outline strictures or masses in the oesophagus, but it is not the first-line test when oesophageal cancer is highly suspected. While it might show an irregular narrowing (“apple-core” lesion) suggestive of a tumour, it only provides an image and cannot confirm a diagnosis. The patient would still need an endoscopy and biopsy afterwards, so doing a barium study first only delays definitive diagnosis. Moreover, if a significant obstruction exists, there’s a risk of the barium study being incomplete or even causing aspiration. Guidelines favour endoscopy directly in dysphagia cases , nice.org.uk. A barium swallow is more appropriate if a motility disorder is strongly suspected (e.g. achalasia) or if prior endoscopy was difficult, but in this scenario of progressive dysphagia with weight loss, it’s inferior to immediate endoscopy. In summary, gastroenterologists typically proceed straight to endoscopy for dysphagia with red flags, making barium swallow an incorrect initial step.
B. Contrast-enhanced CT scan (chest & abdomen): CT imaging is useful after a diagnosis of oesophageal cancer is made, to stage the disease (assess tumour size, local invasion, lymph nodes, metastases). However, it is not the appropriate first investigation to diagnose the cause of dysphagia. CT scans can miss subtle mucosal lesions and, more importantly, cannot provide tissue diagnosis. Even if the CT suggests a mass, you would still need an endoscopic biopsy to confirm cancer. Starting with a CT would thus delay the necessary endoscopy and biopsy. In a patient like this, CT is indicated only after endoscopic confirmation of a tumour, as part of planning treatment. Therefore, CT is not the correct next step for the initial evaluation of progressive dysphagia.
D. Oesophagal manometry: Manometry measures oesophagal motility and pressures; it is the test of choice for diagnosing motility disorders such as achalasia or diffuse oesophagal spasm. It is not indicated as an initial test when a mechanical obstruction (like a tumour or stricture) is likely. In fact, guidelines advise ruling out a structural cause first (with endoscopy) before resorting to manometry. In this scenario, the progressive nature of dysphagia and weight loss point away from a primary motility issue and toward a blockage. Performing manometry without first excluding cancer would be inappropriate. Only if the endoscopy were normal or showed no obstructing lesion would manometric studies be pursued. Thus, manometry is not the correct answer here.
E. Trial of high-dose PPI for 4 weeks: Empirical therapy with a proton pump inhibitor might be considered in a patient with mild dyspepsia or reflux symptoms without alarm features. However, it is dangerously inadequate in the presence of dysphagia and weight loss, which are strong alarm signs. A PPI trial could temporarily relieve reflux or esophagitis, but it will not address an underlying cancer. NICE explicitly recommends urgent investigation over empiric treatment for dysphagia nice.org.uk. In this case, giving a PPI and “watching for improvement” would delay the diagnosis of what could well be an oesophageal carcinoma. In exam terms, this option is a trap: it might seem harmless to try medication first, but doing so in a red-flag scenario contradicts best practice. Therefore, initiating a PPI without endoscopic evaluation is incorrect for this patient.
Clinical Pearl: Progressive dysphagia (solids → liquids) accompanied by weight loss should be assumed to be oesophageal cancer until proven otherwise in the exam setting. Remember the rule: any patient with dysphagia warrants an urgent 2-week endoscopy referral nice.org.uk. Benign causes (like peptic strictures) usually have a relevant history (e.g. long-standing GERD) and still require endoscopy for diagnosis. Never choose conservative management or delay investigation when upper GI cancer is a possibility – exams will expect you to pick the definitive diagnostic step. In PLAB/UKMLA questions, options that delay diagnosis (like “try a PPI” or “schedule a barium study”) are almost always wrong when red flags are present.
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References (Guidelines)
NICE – Suspected Upper GI Cancer (NG12): Recommends urgent direct-access endoscopy (within 2 weeks) for any patient with dysphagia, or age ≥55 with weight loss and another alarm symptom, to rule out oesophageal or stomach cancer nice.org.uk. This 2-week referral pathway (often called the “two-week wait”) is aimed at early diagnosis of upper GI malignancies.
Clinical Methods in Medicine (1990): Notes that chronic, progressive dysphagia typically suggests an oesophagal neoplasm or stricture, whereas intermittent dysphagia points to a motility disorder or ring ncbi.nlm.nih.gov. Progressive difficulty initially with solids and later liquids is a classic presentation of a growing obstruction like cancer.
Esophageal Cancer – Presentation: Oesophageal carcinoma classically presents with rapidly progressive dysphagia (solids then liquids) accompanied by significant weight loss and possibly anorexia en.wikipedia.org. Recognising these symptoms as red flags is critical for timely investigation. (Squamous cell carcinoma risk factors include smoking and alcohol, while adenocarcinoma is linked to chronic GERD/Barrett’s oesophagus en.wikipedia.org— either way, dysphagia warrants prompt endoscopic evaluation.)
