A Treatment Option for Esophageal Intramural Pseudodiverticulosis

A Complex Presentation of Esophageal Pseudodiverticulosis With Candida Albicans Esophagitis in a 68-Year-Old Female

Esophageal pseudodiverticulosis, a rare condition, involves small sac-like structures in the esophageal wall, stemming from dilated excretory ducts of submucosal glands. While uncommon, it can complicate Candida albicans esophagitis, a yeast infection linked to various clinical issues, including pseudodiverticula formation. This unique association underscores the importance of understanding its clinical implications and optimal management. In this case, a 68-year-old female sought medical attention for dysphagia and recurrent food impaction. The diagnostic journey revealed esophageal pseudodiverticulosis and Candida albicans esophagitis, emphasizing the complexity of esophageal disorders.

Esophageal intramural pseudodiverticulosis

Esophageal intramural pseudodiverticulosis (EIPD) is a disease of unknown pathogenesis characterized by usually systemic, cystic dilatation of the excretory ducts of esophageal submucosal glands. In this article, I review the epidemiology, clinical manifestations, endoscopic findings, esophagographic findings, and histopathology of EIPD. I also discuss the etiology and possible pathogenesis of EIPD based on my experiences with this disease and a review of the literature. EIPD usually presents with dysphagia in middle-aged individuals. It is often complicated with secondary infections, most commonly candidiasis. On esophagography, EIPD is delineated as small, multiple, flask-shaped outward projections within the esophageal wall. In recent years, EIPD has been mainly diagnosed by endoscopic findings of multiple, localized, small mucosal depressions. The orifices of the "pseudodiverticula" periodically open and close, and excrete mucus onto the mucosal surface. On histopathological examination, the luminal surface of dilated ducts in EIPD is covered by multilayered, hyperplastic epithelial cells, but myoepithelial cells in the glandular acini are well preserved. Treatment of EIPD is usually symptomatic therapy, and prevention of the infectious complications is important. The etiology and pathogenesis of EIPD are largely unknown, but functional abnormalities of autonomic nerve fibers innervating the esophageal glands likely play an important role, since the structures of the glands are basically preserved in this disease.

Not always eosinophilic esophagitis – intramural pseudodiverticulosis of the esophagus – a case report and literature review

Background Intramural pseudodiverticulosis of the esophagus (EIPD) is a rare disease leading to dysphagia, chest pain, and weight loss. The diagnosis is difficult, and the disease can be confounded with eosinophilic esophagitis (EoE). We present a patient with esophageal intramural pseudodiverticulosis and a literature review.

Case report The 45-year-old white caucasian woman with a history of nicotine and alcohol abuse had progressive hoarseness and severe dysphagia for solid food. Esophagogastroduodenoscopy (EGD) showed proximal esophageal stenosis, thrush esophagitis, and mucosal alteration with trachealization suspicious of EoE. However, repeated bouginage EGD and barium swallow revealed typical signs of esophageal intramural pseudodiverticulosis (EIPD). The patient was treated successfully by bougingage, acid suppression, and antifungal therapy. The literature analysis revealed the characteristics of EIPD according to age, sex, risk factors, and therapy modalities.

Conclusion The case report and the literature overview suggest that EIPD can be confounded with EoE.

Clinical and endoscopic characteristics of diffuse esophageal intramural pseudo-diverticulosis

INTRODUCTION

With 250 published cases worldwide, diffuse esophageal intramural pseudo-diverticulosis (DEIPD) is a poorly understood disease. The aim of this study was to determine the prevalence of DEIPD in our own population, identify risk factors and clinical symptoms, and characterize its typical endoscopic signs.

METHODS

Retrospective search in our center's endoscopic and clinical database. Reviewing of all cases by re-examining stored endoscopic photographs. Reviewing of all cases regarding age, sex, risk factors, comorbidities, histology, and clinical symptoms.

RESULTS

In a population of 150.000 we found 21 cases of DEIPD. Mean age was 56 ± 10 years. 86% were males, 76% had alcohol abuse, 57% had nicotine abuse, 38% had arteriosclerosis, 33% had COPD, 29% had malignancies, 24% had liver cirrhosis, 19% had impaired kidney function, and 15% had diabetes. Dysphagia was present in 62% and food bolus impaction (single or repeated) in 48%. Endoscopically, 95% of patients had multiple (> 4), small (0.25-2.5 mm) pseudodiverticle openings in the esophageal wall. In 62%, openings were aligned longitudinally. 86% showed edematous swelling of mucosa ("frosted glass look"), 76% showed a fine-grained pattern of small (10-100 µm) red dots ("faux uni pattern"), and 76% had a rigid, narrow lumen with multiple rings ("trachealization").

CONCLUSION

With a prevalence of approximately 5 to 50/100.000, DEIPD may be more frequent than previously estimated. It preferably affects middle-aged male alcoholics. Key symptoms are chronic dysphagia and food impaction. Typical endoscopic findings are multiple, small, longitudinally aligned pseudodiverticle openings, frosted glass look, faux uni pattern, and trachealization of the esophagus.

A rare cause of dysphagia due to esophageal intramural pseudodiverticulosis: a case report and review of literature

BACKGROUND

Esophageal intramural pseudodiverticulosis is an uncommon, idiopathic disorder characterized by multiple small outpouchings protruding from the esophageal lumen. Esophageal intramural pseudodiverticulosis is associated with conditions such as gastroesophageal reflux disease and diabetes mellitus, as well as emergent complications including pneumomediastinum. The most common presenting symptom is dysphagia with associated esophageal stricture formation. While the pathogenesis of EIP has yet to be determined, it is important to bring awareness to this unique disease with distinctive diagnostic findings and treatment options.

CASE PRESENTATION

In this case, we present a 62-year-old woman who suffered from dysphagia, an inability to tolerate a regular diet, and unintentional weight loss for several years prior to her diagnoses. She was diagnosed by esophagram and esophagogastroduodenoscopy to have esophageal intramural pseudodiverticulosis, complicated by severe stricture formation. Following treatment with sequential dilatation and maintenance H2-blocker therapy, she achieved significant symptomatic improvement.

CONCLUSIONS

This case highlights the importance of accurate identification and treatment of an uncommon cause of dysphagia, esophageal intramural pseudodiverticulosis. Treatment includes dilatational therapy, as successfully demonstrated in our patient. Furthermore, treatment is focused on optimizing medical management, as demonstrated in our patient with the addition of an H2-blocker for GERD, or addressing potentially serious underlying causes, such as carcinoma, with surgery.

Esophageal intramural pseudodiverticulosis complicated with severe stricture requiring surgical resection

Esophageal intramural pseudodiverticulosis (EIPD) is an uncommon benign disorder leading to esophageal strictures. The etiology remains unknown; however, anti-fungal treatments or endoscopic balloon dilation can improve early esophageal strictures and these rarely require surgical treatment. We report a case of a 46-year-old male with a 6 cm-long esophageal stricture due to EIPD, which did not improve following treatment with an anti-fungal agent, eventually causing aspiration pneumonia. Therefore, we performed a thoraco-laparoscopic esophagectomy, and his symptoms were improved after surgery. This case suggests that a surgical treatment should be considered in patients with extensive, severe strictures attributable to EIPD.

Evaluation of esophageal intramural pseudo-diverticulosis using high-resolution manometry

Esophageal intramural pseudo-diverticulosis (EIPD) is a rare disease characterized by multiple small flask-shaped pouches in the esophageal wall, with the predominant symptom of chronic progressive or intermittent dysphagia. However, its etiology and pathogenesis remain unknown. We present a case of EIPD evaluated with high-resolution manometry in a 75-year-old man with food impaction after eating beef, who came to our emergency department. The patient experienced similar episodes three times previously, though the cause was unknown. Computed tomography (CT) findings revealed diffuse wall thickness in the upper intrathoracic esophagus, while esophagogastroduodenoscopy showed multiple small depressions and several white plaque patches, and a barium meal esophagogram showed characteristic multiple small outpouching areas. From these findings, we diagnosed the patient with EIPD. In addition, high-resolution manometry revealed strong contractions in the distal esophagus. We started an administration of isosorbide dinitrate, because abnormal esophageal motility may have been causative of the condition and development of pseudo-diverticulosis. Thereafter, the patient had a good clinical course without food impaction. Elevated intra-esophageal luminal pressure caused by abnormal esophageal motility seems to be an important factor in the pathogenesis of EIPD in some cases.