What does gastric wall thickening observed during endoscopy mean?

Gastric Wall Thickening on Endoscopy: Diagnostic Implications

Gastric wall thickening observed during endoscopy requires prompt further investigation as it may indicate various conditions ranging from benign inflammatory processes to malignancy, with the most concerning being gastric cancer which has a 5-year survival rate of only 32%. 1

Differential Diagnosis of Gastric Wall Thickening

Gastric wall thickening can be caused by several conditions:

1. Inflammatory conditions:

   • Helicobacter pylori gastritis
   • Other forms of gastritis
   • Peptic ulcer disease (PUD)

2. Malignant conditions:

   • Gastric adenocarcinoma (particularly Borrmann type 4)
   • Gastric lymphoma
   • Gastrointestinal stromal tumors (GISTs)
   • Carcinoid tumors
   • Metastatic disease to the stomach

3. Other conditions:

   • Glomus tumors
   • Hypertrophic gastritis

Diagnostic Approach

Endoscopic Features to Assess

• Wall thickness measurement: Normal gastric wall is typically less than 3.6 mm on endosonography 2
• Presence of ulcerations: Significantly more common in malignancy, particularly advanced gastric cancer 3
• Distribution pattern: Antral involvement is more common in malignancy 3
• Mucosal appearance: Normal-appearing overlying mucosa may be present in subepithelial lesions 1

Endoscopic Ultrasound (EUS) Findings

EUS is crucial for evaluating gastric wall thickening as it can determine:

1. Layer involvement: Different conditions affect different layers of the gastric wall

   • H. pylori gastritis: Typically involves the inner three layers (mucosa-lumen interface, deep mucosa, submucosa) 4
   • Malignancy: Often involves deeper layers including the proper muscle layer 3

2. Layer destruction: Disruption of the normal five-layered gastric wall structure, particularly of the proper muscle layer, strongly suggests malignancy 3

3. Proper muscle layer thickness: A proper muscle thickness >2.39 mm is a significant discriminator between hypertrophic gastritis and advanced gastric cancer 3

Biopsy Strategy

Standard endoscopic biopsies may be insufficient for diagnosis, particularly when:

• The lesion is subepithelial
• The overlying mucosa appears normal
• The pathology is primarily in deeper layers

In these cases:

• EUS-guided sampling may be necessary 5
• Via mucosa incision EUS-guided sampling can be considered for conventional biopsy-negative cases 5
• Large-particle biopsy should be considered when abnormalities involve layers two and three 2

Key Distinguishing Features Between Benign and Malignant Causes

Feature	Benign (e.g., H. pylori gastritis)	Malignant (e.g., Advanced Gastric Cancer)
Layer involvement	Typically inner 3 layers	Often involves deeper layers including proper muscle
Layer destruction	Preserved layered structure	Disruption of normal layered structure
Proper muscle thickness	Usually normal	Often >2.39 mm
Ulceration	Less common	More common
Antral involvement	Less common	More common
Resolution with treatment	May resolve with appropriate therapy	Persists despite treatment

Management Recommendations

1. For suspected H. pylori gastritis:

   • Test for H. pylori infection
   • If positive, treat with appropriate antimicrobial therapy
   • Follow-up EUS after treatment to document resolution of wall thickening 4

2. For suspected malignancy:

   • If standard biopsies are negative but suspicion remains high:
     • Perform EUS with targeted sampling
     • Consider via mucosa incision EUS-guided sampling 5
     • Surgical consultation may be necessary for definitive diagnosis

3. For indeterminate cases:

   • Close follow-up with repeat endoscopy and EUS
   • Consider advanced imaging (CT, MRI) to evaluate for extragastric involvement
   • Low threshold for surgical consultation if diagnosis remains unclear

Pitfalls to Avoid

1. Relying solely on standard endoscopic biopsies: These may miss deeper pathology, with success rates as low as 42.6% in non-ulcerated lesions 3

2. Assuming benign etiology without adequate follow-up: Even presumed benign conditions should be monitored for resolution after appropriate treatment

3. Overlooking the importance of layer involvement: The specific layers affected provide crucial diagnostic information that should guide management decisions

4. Failing to correlate with clinical parameters: Laboratory findings like lower hemoglobin and albumin levels may suggest malignancy 3

5. Not performing EUS when gastric wall thickening is identified: EUS is essential for proper evaluation of gastric wall thickening to determine layer involvement and guide appropriate sampling 1, 2