Synopsis
Recognise oesophago-gastric cancer alarm presentations, choose the correct urgent referral route, preserve airway and nutrition during obstruction, and close the loop on endoscopy and histology.
- Refer on the NICE NG12 suspected oesophago-gastric cancer pathway for dysphagia at any adult age, or age 55 or over with weight loss plus upper-abdominal pain, reflux or dyspepsia. Also consider this pathway for an upper-abdominal mass consistent with gastric cancer.
- Normal haemoglobin does not neutralise progressive dysphagia. NG12 has a separate non-urgent direct-access endoscopy branch: haematemesis after appropriate acute-bleeding assessment, and specified combinations from age 55 involving resistant dyspepsia, low haemoglobin, raised platelets, nausea or vomiting. The full combinations are listed under investigations.
- Ask about speed of progression, solids and liquids, pain, regurgitation, bleeding, appetite, weight trajectory, smoking, alcohol, reflux and previous gastric surgery.
Key red flags
Dysphagia itself triggers suspected oesophageal or gastric cancer referral under NICE, irrespective of age or an existing reflux diagnosis.
Haematemesis, melaena, progressive vomiting, iron-deficiency anaemia and unintended weight loss increase urgency and require physiological as well as diagnostic assessment.
Solids-first progression with weight loss is a common obstructive cancer pattern, although liquid difficulty may appear when narrowing becomes advanced.
Drooling and inability to swallow saliva indicate emergency obstruction regardless of the underlying histology.
Reasoning priorities
Apply NG12 eligibility and inspect and biopsy the oesophagus and stomach.
Dysphagia is sufficient at any adult age; age 55 or over with weight loss plus upper-abdominal pain, reflux or dyspepsia is a separate referral trigger. Also consider suspected-cancer referral for an upper-abdominal mass consistent with gastric cancer. These outpatient criteria do not replace emergency assessment for secretion intolerance, unstable bleeding or perforation.
Worked reasoning
A 70-year-old has six weeks of solids-first dysphagia, an 8 kg measured weight loss and reduced oral intake, but can still swallow fluids and has stable observations.
- Refer immediately on the suspected oesophago-gastric cancer pathway, document the continuing ability to drink and arrange dietetic support rather than delaying for an acid-suppression trial.
- Upper-GI endoscopy five days later identifies a tight ulcerated distal oesophageal lesion from 35 to 40 cm; the endoscopist records that it is not safely traversable and obtains eight viable biopsies from non-necrotic edges without dilating the malignant narrowing.
- Histology confirms adenocarcinoma and staging CT shows no distant metastasis, so the referral is transferred directly to the specialist oesophago-gastric MDT for radical assessment.
- Verify that the patient has received the result, is maintaining hydration on a modified liquid diet and has a named MDT appointment; repeat weight at review shows no further loss while staging is completed.