What is the diagnosis and treatment for a patient presenting with bloatedness, jaundice, and abdominal pain, with a CT (Computed Tomography) scan showing gastric wall thickening?

Gastric Wall Thickening with Jaundice: Likely Gastric Adenocarcinoma with Biliary Obstruction

The combination of gastric wall thickening on CT with jaundice strongly suggests gastric adenocarcinoma with metastatic lymph node involvement causing biliary obstruction, requiring urgent upper endoscopy with biopsy for tissue diagnosis. 1

Immediate Diagnostic Priorities

Assess for Life-Threatening Complications on CT

• Review the CT scan for perforation by identifying extraluminal gas (present in 97% of perforated cases), focal wall defect/ulcer (84% of cases), or combined wall defect plus thickening (95% sensitivity, 93% specificity for perforation localization) 1, 2
• Look for fluid or fat stranding along the gastroduodenal region, which occurs in 89% of perforation cases 1
• Evaluate for gastric outlet obstruction from luminal narrowing due to edema or chronic inflammation near the pylorus 1
• Check for active bleeding indicated by hyperdense blood products or contrast extravasation 1

Evaluate the Jaundice Component

• Assess for lymphadenopathy around the hepatoduodenal ligament, pancreas head, portal vein, and celiac axis on CT, which can cause obstructive jaundice from metastatic gastric cancer 3
• Look for biliary dilatation on CT as evidence of biliary obstruction 4
• The presence of jaundice with gastric wall thickening significantly elevates concern for advanced malignancy with nodal metastases causing biliary compression 3

Primary Differential Diagnosis

Gastric Adenocarcinoma (Most Likely)

• Nodular or irregular wall thickening with soft tissue attenuation on CT strongly suggests adenocarcinoma rather than benign disease 4, 1
• Wall thickening >1.5 cm, asymmetric or focal thickening, and nodularity are CT features that suggest malignancy 5
• Gastric cancer has a 56% positive predictive value when gastric wall thickening is identified on imaging 6
• The combination of gastric wall thickening plus jaundice indicates metastatic lymph node involvement causing biliary obstruction, representing advanced disease 3

Less Likely Benign Causes

• Peptic ulcer disease presents with wall thickening from submucosal edema with mucosal hyperenhancement, focal outpouching (ulcer craters), and focal interruption of mucosal enhancement 1, 2
• Target or double-ringed appearance of thickened wall suggests benign disease, but this is less consistent with the clinical presentation of jaundice 5
• Benign gastric conditions (gastritis, ulcers) rarely cause jaundice unless complicated by severe inflammation extending to biliary structures 7

Critical CT Technical Assessment

Verify Adequate CT Technique

• Confirm IV contrast was administered, as it is essential for detecting mucosal hyperenhancement, interrupted enhancement, and distinguishing inflammatory from neoplastic processes 1, 2
• Check if neutral oral contrast (water or dilute barium) was used rather than positive contrast, which can obscure mucosal enhancement 1, 2
• Assess gastric distension adequacy (requires 600-800 mL of water or neutral oral contrast); inadequate distension can cause false-positive wall thickening 1

Review for Metastatic Disease

• Systematically evaluate for distant metastases including liver lesions, peritoneal implants, and ascites 1
• Document extent of lymphadenopathy particularly around hepatoduodenal ligament, celiac axis, and porta hepatis 3

Definitive Diagnostic Algorithm

Step 1: Immediate Management Based on CT Findings

• If perforation, obstruction, or active bleeding is present, obtain immediate surgical consultation before endoscopy 1
• If biliary obstruction is severe (markedly elevated bilirubin, cholangitis signs), consider percutaneous transhepatic cholangio-drainage (PTCD) or ERCP for biliary decompression before definitive diagnosis 3

Step 2: Upper Endoscopy with Biopsy (Reference Standard)

• Upper endoscopy with biopsy is mandatory as the reference standard for diagnosing gastric cancer, providing both tissue diagnosis and therapeutic intervention 4, 1, 8
• Endoscopy demonstrates abnormalities in 67% of patients with bowel wall thickening on CT, with 42% yielding specific histological diagnosis 8
• In patients with gastric wall thickening on CT, endoscopy should be strongly considered even when specific diagnosis is not evident, as it permits direct visualization and biopsy 8

Step 3: Staging and Treatment Planning

• If adenocarcinoma is confirmed, complete staging with chest CT and consideration of PET-CT for metastatic evaluation 4
• For obstructive jaundice from metastatic nodes, biliary drainage followed by systemic chemotherapy (such as FLP combination therapy: 5-fluorouracil, leucovorin, cisplatin) may provide palliation 3

Common Pitfalls to Avoid

• Do not delay endoscopy in stable patients without complications; tissue diagnosis is essential and cannot be reliably made by CT alone 8
• Do not assume benign disease based solely on diffuse thickening pattern, as some infiltrating malignancies present this way 5
• Do not overlook the significance of jaundice in this context—it transforms a potentially localized gastric problem into likely metastatic disease requiring different management 3
• Do not perform fluoroscopic upper GI series instead of endoscopy when malignancy is suspected, as tissue diagnosis is required 4