What is the differential diagnosis for someone presenting with coffee ground emesis and wall thickening of the mid to distal esophagus on computed tomography (CT) scan?

Differential Diagnosis for Coffee Ground Emesis with Mid-to-Distal Esophageal Wall Thickening

The most critical immediate consideration is esophageal malignancy (adenocarcinoma or squamous cell carcinoma), followed by severe reflux esophagitis with bleeding, and less commonly necrotizing esophagitis or caustic injury. Upper endoscopy with biopsy is mandatory to distinguish between these entities and guide management 1.

Primary Differential Diagnoses

Esophageal Malignancy (Highest Priority)

• Esophageal adenocarcinoma or squamous cell carcinoma must be excluded first, as distal esophageal wall thickening combined with upper GI bleeding is a classic presentation 2.
• CT findings of circumferential wall thickening in the mid-to-distal esophagus (≥5 mm) with irregular mucosa strongly suggest malignancy, particularly in older patients 2.
• Coffee ground emesis indicates bleeding from an ulcerated tumor mass, which can occur with advanced esophageal cancer 2, 3.
• Critical action: Urgent upper endoscopy with multiple biopsies from different esophageal locations is required, even if the mucosa appears grossly normal in some areas 1.

Severe Reflux Esophagitis with Bleeding

• Gastroesophageal reflux disease (GERD) with complicated esophagitis is a common cause of distal esophageal wall thickening (≥5 mm), with 88% specificity on CT 1.
• Mucosal hyperenhancement, submucosal edema, and wall thickening on CT suggest active inflammation with potential bleeding 1.
• However, coffee ground emesis is less commonly associated with uncomplicated GERD compared to other bleeding sources 3.
• The presence of air in the middle and lower esophagus on CT supports GERD as a contributing factor 1.

Peptic Ulcer Disease with Esophageal Involvement

• Gastric or duodenal ulcer disease can present with coffee ground emesis and may have associated esophageal inflammation 1, 4.
• CT findings include gastric/duodenal wall thickening, mucosal hyperenhancement, focal outpouching from ulcerations, or active bleeding with hyperdense blood products 1, 5.
• Look for focal wall defects, interruption of mucosal enhancement, or extraluminal gas if perforation is present 1, 5.

Necrotizing Esophagitis (Black Esophagus)

• Acute esophageal necrosis presents with coffee ground emesis and can show esophageal wall thickening on imaging 6.
• This is typically seen in elderly patients with significant cardiac history, low-flow states, or severe systemic illness 6.
• Endoscopy reveals characteristic black discoloration of the esophageal mucosa 6, 7.

Eosinophilic Esophagitis

• EE can cause esophageal wall thickening involving the mucosa, submucosa, and muscularis propria layers 1.
• Typically presents with dysphagia rather than bleeding, but mucosal tears can occur 1.
• Endoscopic features include linear furrowing, white exudates, circular rings, and "crepe paper" mucosa 1.
• Requires multiple esophageal biopsies showing ≥15 eosinophils per high-power field 1.

Caustic Injury (If History Suggests)

• Corrosive esophagitis from caustic ingestion causes wall thickening with specific CT patterns 1.
• Grade IIa injuries show internal mucosal enhancement with hypodense thickened wall ("target sign") 1.
• Grade IIb shows fine rim of external wall enhancement with non-enhancing necrotic mucosa 1.
• Mediastinal fat stranding is uniformly present in Grade II injuries 1.

Less Common Considerations

• Diffuse esophageal spasm can cause smooth, symmetric, circumferential wall thickening of the distal two-thirds of the esophagus, but does not typically cause bleeding 8.
• Gastric volvulus with paraesophageal hernia may present with coffee ground vomiting and esophageal changes from ischemia 7.
• Infectious esophagitis (Candida, HSV, CMV) in immunocompromised patients can cause wall thickening and bleeding 1.

Critical Next Steps

Immediate Evaluation

• Check for perforation signs immediately: Look for extraluminal gas, fluid or fat stranding around the esophagus, ascites, and focal wall defects on the existing CT 1, 5, 4.
• Perforation carries up to 30% mortality if treatment is delayed and requires emergent surgical consultation 1, 5, 4.
• Assess hemodynamic stability and need for blood transfusion based on severity of bleeding 3.

Diagnostic Algorithm

1. Urgent upper endoscopy with biopsy is the definitive next step to distinguish malignancy from benign causes 1, 5.
2. Obtain biopsies from multiple esophageal locations (proximal, mid, distal) even if mucosa appears normal, as sensitivity increases from 55% with one biopsy to 100% with five biopsies 1.
3. Also biopsy stomach and duodenum to evaluate for concurrent gastritis, PUD, or eosinophilic gastroenteritis 1, 5.
4. If endoscopy shows severe esophagitis but no mass, consider 6-8 weeks of high-dose PPI therapy with repeat endoscopy to distinguish GERD from eosinophilic esophagitis 1.

Common Pitfalls to Avoid

• Never assume benign peptic ulcer disease or esophagitis without histologic confirmation when wall thickening and bleeding are present, as malignancy can present identically 5, 4, 2.
• Do not delay endoscopy in patients with coffee ground emesis and esophageal wall thickening, as this combination warrants aggressive investigation for malignancy 5, 2.
• Do not overlook perforation signs on the existing CT scan—look specifically for extraluminal gas, wall defects, and fat stranding, as these require immediate surgical intervention 1, 5, 4.
• Avoid attributing all esophageal eosinophilia to GERD without adequate biopsy sampling and consideration of eosinophilic esophagitis 1.
• Coffee ground vomiting alone has lower endoscopic yield than frank hematemesis, but when combined with CT abnormalities, it mandates thorough evaluation 3.