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8.2.
1. An 80 year old male patient presents with cervical dysphagia. His wife confirms severe halitosis
and intermittent regurgitation of food into his mouth (that he spits out).
What is the most likely diagnosis?

Although he falls in the right age group for development of a cancer, and even a cervical
oesophageal squamous cell carcinoma, the fact that he has halitosis points to an underlying
Zenker’s diverticulum. The food is not regurgitated up immediately as in patients with cancer,
but tends to get stuck in the diverticulum where rotting causes halitosis.
2, A 25 year old female patient presents with thoracic dysphagia that has been present for the
past two years. The dysphagia is present for liquids and solids to the same degree and is relieved
by drinking warm water with meals. She admits to occasional regurgitation of food into her
mouth and has lost a significant amount of weight. She denies the presence of any chest pain.
What is the likely diagnosis?

ACHALASAI
3. A 58 year old male patient from the Eastern Cape presents with progressive dysphagia
indicated the lower cervical area. Initially the only food that got stuck was pieces of meat and
bread. Currently he can swallow thick milk and water but not much more, and he has severe loss
of weight. He is a smoker but has no other comorbid diseases. On examination you find a
cachectic patient and a palpable left supraclavicular lymph node.
What is the most likely diagnosis
Metastatic squamous cell carcinoma
4. A 28 year old male patient presents with thoracic dysphagia for solids (meat and bread). He
has no comorbidities but a few months ago he experienced an episode of break fluid ingestion.
On examination you find minimal weight loss, but a crackles on the right lower lobe of the lung.
What is the most likely diagnosis?
Caustic stricture with aspiration -This is most likely a benign stricture of the oesophagus due to
caustic injury (not full thickness) of the oesophagus. The presence of lung crackles creates
concern for aspiration of regurgitated food, possibly due to a laryngeal burn that occurred at
the same time as the caustic ingestion.
5. A 66 year old lady with a BMI of 55 complains of dysphagia. She has a 5 year history of
hypertension, diabetes and gastro-esophageal reflux (GERD). Her dysphagia is thoracic and for
meat and bread. On examination she has no palpable lymph nodes or organomegaly, and no
ascites.
What is your investigation of choice to secure a diagnosis?
This patient is known with longstanding GERD and can thus have dysphagia due to an acute
oesophagitis, a benign oesophageal reflux stricture, the development of Barrett’s oesophagus,
or the development of an oesophageal adenocarcinoma. A gastroscopy will reveal the diagnosis
while biopsies at the time of gastroscopy will confirm the diagnosis.
6. What is the investigation of choice in a patient presenting with dysphagia likely due to an
underlying oesophageal carcinoma?
A CT chest and abdomen is the staging investigation of choice AFTER the diagnosis of an
oesophageal cancer has been confirmed with biopsies at the time of gastroscopy.
7. Which three investigations are used to confirm the diagnosis in a patient suspected to have
achalasia? Gastroscopy, contrast swallow and manometry
This is termed the triple test performed for the diagnosis of achalasia. Although the gastroscopy
and contrast swallow can be ‘suggestive’ of achalasia, the manometry secure the final definitive
diagnosis (gold standard test for achalasia). Gastroscopy is necessary to exclude a mucosal
abnormality as the cause for the dysphagia and contrast swallow reveals a typical bird’s beak
deformity.
8.2.2.DETECTING UD AND GASTRIC CANCER
1.A 25 year old male is a truck driver and takes Grandpa powder daily for headaches.
He is admitted to the emergency department with a history of haematemesis (one
episode – three cups) earlier in the day. On examination his pulse rate is 110
beats/minute and his blood pressure 120/65 mmHg. His abdominal examination is
unremarkable and on rectal examination black, sticky, tarry stool is found. What is the
most likely diagnosis?
Peptic ulcer bleed with hypovolemic shock
The history of non-steroidal anti-inflammatory drug (NSAID) use in the form of Grandpa powder
is a clear risk factor for a peptic ulcer. The most common complication of peptic ulcer disease is
an Upper Gastrointestinal bleed - here in the form of haematemesis and melena (sticky, black
tarry stool). The tachycardia denotes the presence of early shock.
2. A 65 year old lady is known with chronic osteoarthritis – well controlled with medication. She
presents to the emergency unit with a history of abdominal pain – the pain started while she
was baking bread for lunch. On examination she is tachycardic and slightly hypotensive, and her
abdomen reveals diffuse guarding and rebound tenderness. What is the investigation of choice
to confirm your suspected diagnosis?
Erect chest radiography
The history of non-steroidal anti-inflammatory drug (NSAID) use in this patient makes an
underlying peptic ulcer very likely. The acute onset of abdominal pain suggests that she has
developed a complication namely perforation. In 85% of patients with a perforated peptic ulcer,
free air will be seen underneath the right diaphragm (wedged between the liver and
diaphragm).
3. A 55 year old male smoker and methamphetamine user presents to the clinic with a history
of significant weight loss. On further history taking he admits to vomiting every second or third
day. The vomit contains undigested foul smelling food and he can recognise the Erect chest
radiography Serum lipase Urine dipstix Abdominal computed tomography SUBMIT food as that
which he consumed over the past few days. On examination he is stable, but wasted, and on
abdominal examination you elicit a clear succussion splash. Which acid base and electrolyte
abnormality do you expect his bloodgas to reveal?
This clinical picture is classic of a gastric outlet obstruction (GOO) secondary to a peptic ulcer
obstruction of the pyloric channel / gastric antrum. In these patients a hyponatremic,
hypokalemic, hypochloremic metabolic alkalosis is the typical bloodgas abnormality seen
4. How can the following chest radiograph be best described?
This erect chest xray clearly demonstrates free air under both the right and left diaphragms.
Most often free air is witnessed under the right diaphragm (air wedged between the liver and
diaphragm), but here free (extraluminal) air is also visible below the left diaphragm. This
radiological sign indicates free air in the abdominal cavity (pneumoperitoneum) as is secondary
to perforated bowel, most commonly a perforated peptic ulcer.

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8.2.

What is the most likely diagnosis?

What is the likely diagnosis?

Metastatic squamous cell carcinoma

What is the most likely diagnosis?

8.2.2.DETECTING UD AND GASTRIC CANCER

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