Synopsis
Recognise oesophageal cancer promptly, use the current UK suspected-cancer pathway without diluting dysphagia as a red flag, and understand how endoscopy, staging, nutrition and multidisciplinary treatment fit together.
- NICE recommends a suspected-cancer pathway referral for dysphagia at any adult age; a trial of acid suppression must not postpone that referral.
- People aged 55 or over with weight loss plus upper abdominal pain, reflux or dyspepsia also meet the oesophageal or stomach cancer referral threshold.
- Progression from difficulty with solids to difficulty with liquids suggests mechanical narrowing, although advanced dysmotility and benign strictures remain important differentials.
- Upper-GI endoscopy defines the lesion and provides histology; biopsy technique and lesion description should support treatment planning rather than merely record a narrowed lumen.
- Squamous-cell carcinoma and adenocarcinoma differ in distribution, risk pattern and treatment options, so histological subtype and exact relationship to the gastro-oesophageal junction matter.
- Potentially curative disease is staged through an oesophago-gastric MDT using cross-sectional imaging, PET-CT and selective EUS or laparoscopy according to the clinical question.
- Malnutrition and sarcopenia are common at diagnosis; swallowing safety and dietetic intervention should begin during staging, not after a final treatment decision.
- Endoscopic resection can cure carefully staged superficial neoplasia, while more advanced local disease may require surgery, chemotherapy, chemoradiotherapy or a definitive non-operative strategy.
Key red flags
New food sticking, prolonged mealtimes or avoidance of meat and bread may precede obvious liquid dysphagia. Ask where food seems to stick, but remember that perceived level does not reliably locate the lesion.
Nocturnal regurgitation, coughing after swallowing, recurrent chest infection or a wet voice can reflect proximal pooling above an obstruction. Inability to manage saliva is an acute obstruction warning.
Investigation priorities
Visualise the obstruction, define its extent and obtain diagnostic histology.
Management branches
An adult reports dysphagia, or a person aged 55 or over has weight loss with upper abdominal pain, reflux or dyspepsia.
- Clarify progression, intake, weight, aspiration, bleeding and performance status, examine for metastatic signs, and submit a suspected-cancer referral using the applicable devolved-nation or local route.
- Safety-net immediate deterioration, particularly inability to swallow saliva, food-bolus obstruction, haematemesis or severe chest pain, because these features require acute assessment rather than waiting for an appointment.
- Do not substitute empirical PPI treatment, a normal plain radiograph or an old benign endoscopy for current investigation of a new qualifying symptom.