What is the best course of action for a patient presenting with gastric thickening and jaundice, potentially indicating malignancy or other serious conditions?

Gastric Thickening Presenting with Jaundice

A patient presenting with gastric thickening and jaundice requires urgent contrast-enhanced CT abdomen and pelvis with IV contrast and neutral oral contrast to evaluate for gastric malignancy with biliary obstruction, followed by upper endoscopy with biopsy for definitive diagnosis. 1

Immediate Diagnostic Priorities

This presentation is highly concerning for gastric adenocarcinoma causing biliary obstruction through direct extension, lymphadenopathy, or hepatic metastases. Malignancy is a leading cause of severe jaundice in multiple international studies, and gastric cancer specifically can present with obstructive jaundice. 1

Critical Laboratory Evaluation

• Obtain fractionated bilirubin immediately to determine if hyperbilirubinemia is conjugated (obstructive) or unconjugated, as this determines the entire diagnostic pathway 2, 3
• Measure hepatic function panel including AST, ALT, alkaline phosphatase, GGT, albumin, and coagulation studies (PT/INR) 2, 3
• Check for coagulopathy (INR >1.5) and assess for encephalopathy, which indicate fulminant hepatic failure requiring immediate hepatology consultation 2
• Obtain blood and urine cultures if fever is present, as sepsis accounts for 22% of new-onset jaundice and can complicate malignancy 2

Imaging Algorithm

First-line imaging: Contrast-enhanced CT abdomen and pelvis with IV contrast

• CT should be performed with IV contrast and neutral oral contrast (water or dilute barium) to optimally visualize gastric wall thickening and assess for nodular or irregular enhancement, soft tissue attenuation, lymphadenopathy, and distant metastases 1
• CT is superior to ultrasound for detecting gastric malignancy, identifying concerning features including nodular wall thickening, soft tissue attenuation rather than edematous thickening, perforation with ulcerated mass, and metastatic disease 1
• Including the pelvis is essential for assessing distant metastases and provides comprehensive staging 1
• CT can simultaneously evaluate the biliary tree for obstruction and identify the level and cause of obstruction (mass effect, lymphadenopathy, hepatic metastases) 1

Alternative if CT contraindicated: MRI abdomen with MRCP

• MRI can demonstrate both gastric pathology and biliary obstruction, though CT is preferred for its ability to detect free air from perforation and shorter acquisition time 1

Definitive Diagnosis

Upper endoscopy with biopsy is the reference standard for diagnosing gastric cancer and must be performed once imaging confirms suspicion 1

Management of Biliary Obstruction

If Conjugated Hyperbilirubinemia Confirmed

• Assess for Charcot's triad (fever, right upper quadrant pain, jaundice) suggesting acute cholangitis requiring urgent biliary decompression 2
• Determine obstruction level and etiology from CT findings to guide intervention (ERCP vs. percutaneous drainage vs. surgical approach) 1
• If malignant obstruction is confirmed, biliary drainage may be required before definitive oncologic therapy 4

Critical Pitfalls to Avoid

• Do not obtain CT without IV contrast for this indication, as it will be significantly less sensitive for detecting gastric malignancy and characterizing wall thickening 1
• Do not start with ultrasound alone when gastric pathology is suspected, as overlying bowel gas limits visualization of the stomach and distal common bile duct 1
• Do not delay endoscopy once imaging suggests gastric malignancy, as tissue diagnosis is essential for treatment planning 1
• Avoid nephrotoxic agents and iodinated contrast if acute kidney injury or significant renal dysfunction is present, as AKI can complicate the clinical course 1, 2
• Do not assume benign etiology in a patient with gastric thickening and jaundice, as this combination strongly suggests malignancy with advanced disease 1

Prognostic Considerations

Gastric adenocarcinoma has a 5-year relative survival rate of only 32%, and presentation with jaundice suggests advanced disease with biliary involvement through metastases or direct extension. 1 The presence of obstructive jaundice in gastric cancer indicates poor prognosis and necessitates urgent multidisciplinary evaluation for potential palliative biliary drainage and systemic therapy. 4, 5