What are the next steps for a patient with esophageal thickening identified on a Computed Tomography Angiography (CTA)?

Esophageal Thickening on CTA: Next Steps

Upper endoscopy with biopsy is the definitive next step for any patient with esophageal thickening identified on CTA, as this finding has a 54% malignancy rate in patients with alarm symptoms and cannot be reliably distinguished from benign causes by imaging alone. 1, 2

Immediate Assessment

Rule out perforation first by reviewing the existing CTA for:

• Extraluminal air (present in 97% of perforations) 3
• Periesophageal fluid collections (seen in 89-92% of perforations) 3
• Mediastinal fat stranding 4, 3
• Focal wall defects 3

If any perforation signs are present, this constitutes a surgical emergency requiring immediate intervention, as mortality reaches 30% with delayed treatment. 3, 5

Characterize the CT Findings

Analyze the pattern and location of thickening to guide differential diagnosis:

Symmetric vs. Asymmetric Thickening:

• Symmetric thickening <10mm suggests benign causes (achalasia, esophagitis, diffuse esophageal spasm) 6, 7, 8
• Asymmetric thickening or thickness >10mm strongly suggests malignancy (pseudoachalasia, esophageal cancer) 6

Distribution Pattern:

• Distal esophageal involvement: Consider GERD/esophagitis (88% specificity when mucosal hyperenhancement and submucosal edema present) 5
• Long segment circumferential thickening: Suggests esophagitis or diffuse esophageal spasm 7, 8
• Focal mass-like thickening: Highly suspicious for malignancy 6

Associated CT Features:

• Target sign (internal mucosal enhancement with hypodense thickened wall): Seen in 17% of esophagitis cases, also in caustic injury 4, 5, 7
• Absence of post-contrast wall enhancement: Indicates transmural necrosis requiring emergency surgery 4
• Mediastinal air: Present in middle/lower esophagus supports GERD 5

Definitive Diagnostic Workup

Urgent upper endoscopy with comprehensive biopsy is mandatory for all patients with esophageal thickening on CTA, regardless of clinical presentation. 5, 1, 2

Endoscopic protocol:

• Obtain biopsies from multiple esophageal locations (proximal, mid, distal) even if mucosa appears normal—sensitivity increases from 55% with one biopsy to 100% with five biopsies 5
• Include stomach and duodenum biopsies to evaluate for concurrent gastritis, peptic ulcer disease, or eosinophilic gastroenteritis 5
• Use low-flow CO2 insufflation rather than air to minimize perforation risk 4, 3

If initial mucosal biopsies are negative but wall thickening persists:

• Proceed to EUS-guided mural trucut biopsy, which has 85% sensitivity and 100% specificity for detecting submucosal malignancy 1
• EUS-TCB obtains adequate specimens in 90% of cases and identifies malignancy in 54% of patients with negative mucosal biopsies 1

Clinical Context Considerations

History of caustic ingestion:

• CT should have been performed 3-6 hours post-ingestion with IV contrast 4, 9
• Grade IIa injuries show target sign; Grade III shows absent wall enhancement requiring surgery 4, 9
• Endoscopy should be performed within 12-48 hours unless perforation or supraglottic burns are present 9

Trauma history:

• CT esophagography has 95% sensitivity and 91% specificity for traumatic esophageal injury 4
• Flexible endoscopy should be added as adjunct, altering management in 69% of cases 4, 3
• Triple endoscopy (esophagoscopy, laryngoscopy, bronchoscopy) indicated for penetrating neck injuries 4

Dysphagia or alarm symptoms:

• 8.2% of endoscopies are performed specifically for radiologic distal esophageal thickening 2
• These patients have significantly higher rates of abnormal findings and cancer compared to other indications 2
• Risk factors like Barrett's esophagus or tobacco use do NOT predict malignancy—all patients require endoscopy 2

Critical Pitfalls to Avoid

• Never assume benign disease without histologic confirmation—malignancy presents identically to esophagitis or peptic disease on imaging 5, 1
• Do not delay endoscopy in patients with esophageal wall thickening and any alarm symptoms, as this combination warrants aggressive investigation 5, 2
• Do not overlook perforation signs on the existing CTA—extraluminal gas, wall defects, and fat stranding require immediate surgical consultation 3, 5
• Do not rely on clinical symptoms alone—physical examination is unreliable for early diagnosis of esophageal pathology 4, 9
• Do not stop at negative mucosal biopsies—proceed to EUS-guided mural biopsy if clinical suspicion remains high 1