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A 68-year-old man presented with a 3-month history of progressive dysphagia, anorexia, weight loss, fatigue and malaise. Two years previously, he had received palliative radiotherapy for squamous cell carcinoma of the right bronchus. There was no medical history of gastrointestinal disease and, apart from difficulty swallowing, the patient did not complain of any other gastrointestinal symptoms, urinary symptoms, or visual disturbance. On examination, the patient was alert, but cachectic. There were no signs of cognitive impairment. There was no palpable lymphadenopathy or other mass in the neck. Examination of the mouth and pharynx revealed no abnormalities. Respiratory examination revealed collapse of the right lower lobe. Abdominal examination revealed a hard, irregular, non-tender, non-pulsatile liver edge, palpable 4 cm below the right costal margin. There were no signs of chronic liver disease. Rectal, cardiovascular and neurological examinations were normal. Investigations showed haemoglobin 10.3 g/dl, mean corpuscular volume 78.2 fl, total white blood cell count 8.45 × 10 …
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