Endoscopic ultrasound in the investigation of unexplained thickening of esophagogastric wall

We read with interest the study by Thomas et al. [1] that highlighted the role of endoscopic ultrasound (EUS)-guided mural trucut biopsies (TCB) in patients with esophagogastric wall thickening and negative endoscopy and mucosal biopsies. The patients with thickened esophageal wall on computed tomography (CT) and normal mucosa on endoscopy as well as negative endoscopic biopsy pose a difficult diagnostic challenge. These patients usually undergo repeated endoscopic biopsies or fine-needle aspiration (FNA) under endoscopic guidance, with poor diagnostic yield. EUS-guided FNA has improved immensely our diagnostic capability but the sensitivity of this technique is low for focal mural lesions [2] [3]. The study by Thomas et al. [1] has shown that EUS-TCB is a safe technique with a high sensitivity for evaluating patients with unexplained esophagogastric wall thickening, and thus will help in solving clinical dilemmas like the one we encountered in one of our patients.

A 46-year-old male presented to us with progressively increasing dysphagia along with weight loss and loss of appetite of 4 months’ duration. There was no history of corrosive ingestion or long-standing reflux disease. Upper gastrointestinal endoscopy carried out at a peripheral center had revealed a non-negotiable stricture at 30 cm from the incisor teeth, and the mucosal biopsy was inconclusive. Barium swallow examination revealed a long segment stricture in the lower esophagus, and CT examination revealed a thickened lower esophageal wall with minimal right-sided pleural effusion ([Fig. 1]).

Fig. 1 Computed tomography of the chest: thickened esophageal wall with minimal right pleural effusion.

Examination of the pleural fluid did not reveal any evidence of malignancy. There was also a 1.5-cm sized nodule in the right lung. An upper gastrointestinal endoscopy was repeated after bougie dilatation of the stricture, and the mucosa in the strictured segment of the esophagus was found to be normal. Multiple endoscopic biopsies taken from the strictured segment were inconclusive. Thereafter, EUS was performed and it revealed an asymmetrically thickened esophageal wall with loss of differentiation of the different wall layers ([Fig. 2]).

Fig. 2 Endoscopicultrasound: asymmetrically thickened esophageal wall with minimal right pleural effusion. The descending aorta is not involved.

The maximum thickness of the wall was 18 mm, and color Doppler examination did not show increased vascularity in this thickened region ([Fig. 3]).

Fig. 3 Color Doppler does not show increased vascularity in the thickened esophageal wall.

EUS-guided FNA from the esophageal wall was inconclusive. Subsequently, CT-guided FNA cytology from the right lung nodule revealed features suggestive of adenocarcinoma. Thereafter, the patient was referred to the oncology services and was given chemoradiotherapy.

As there was no relief in dysphagia after three cycles of chemotherapy, an esophageal self-expanding metallic stent (SEMS) was inserted. Following this, the patient showed marked improvement in dysphagia and was free of dysphagia at the last follow-up 1 month after SEMS insertion.

The results of the study by Thomas et al. [1] are encouraging and clinically relevant for patients with unexplained esophagogastric wall thickening. It is possible that EUS-TCB may have been helpful in establishing the diagnosis in our patient also.

Competing interests: None

References

• 1 Thomas T, Kaye P V, Ragunath K, Aithal G P. Endoscopic-ultrasound-guided mural trucut biopsy in the investigation of unexplained thickening of esophagogastric wall.  Endoscopy. 2009;  41 335-339
• 2 Wiersema M J, Vilmann P, Giovannini M. et al . Endosonography guided fine needle aspiration biopsy: diagnostic accuracy and complications assessment.  Gastroenterology. 1997;  112 1087-1095
• 3 Pellise-Urquisa M, Fernandez-Esparrach G, Sole M. et al . Endoscopic ultrasound-guided fine needle aspiration: predictive factors of accurate diagnosis and cost-minimization analysis of on-site pathologist.  Gastroenterol Hepatol. 2007;  30 319-324