Significance of thickening of the upper gastrointestinal tract on cross sectional imaging: Endoscopic correlation

To report the endoscopic findings for a cohort of patients referred for discussion at a specialist oesophago-gastric multi-disciplinary team (MDT) meeting, on the basis of CT mural thickening.

The records of patients discussed at a regional oesophago-gastric MDT during the time 1^st April 2014 to 5^th February 2016 were reviewed in order to identify patients who were endoscopy naïve at the time of CT and scans re-reviewed to measure maximum wall thickness.

456 patients were referred for discussion, 126 met the inclusion criteria. Endoscopy confirmed malignancy in 50/126 patients (40%); by site, oesophagus (21/67, 31%), stomach (25/50, 50%), duodenum (4/9, 44%). Malignancy was confirmed for 10/48 (21%) patients with isolated wall thickening, for 11/33 (33%) when regional lymphadenopathy was identified, and for 28/44 (64%) when possible metastatic disease was identified. The commonest source of diagnostic uncertainty was thickening around the gastro-oesophageal junction in the presence of a hiatal hernia. Wall thickening >20 mm was strongly associated with malignancy compared to thickening =<20 mm (p < 0.0001). Using this threshold would have resulted in a sensitivity of 32/50 (64%), a specificity of 55/76 (72%), a positive predictive value of 32/53 (60%) and a negative predictive value of 55/73 (75%) in this cohort.

The cancer pick-up rate of 40% and the medicolegal consequences of a missed cancer suggest that endoscopy should be performed in all patients with CT identified mural thickening. In the presence of isolated mural thickening and a normal endoscopy, no formal MDT discussion is required.