Esophageal Intramural Pseudodiverticulosis: A Rare Endoscopic Finding and Clinical Review

Abstract

Introduction: Esophageal intramural pseudodiverticulosis (EIP) is a rare, but benign condition characterized by numerous outpouchings within the esophageal wall. These pseudodiverticula correspond to inflamed excretory ducts of the submucosal esophageal glands, which can lead to fibrosis and subsequent narrowing of the esophageal lumen, resulting in dysphagia. While the pathogenesis is not known, gastroenterologists should be aware of this unique endoscopic finding and its treatment. We present a patient with previously treated esophageal candidiasis with progressive dysphagia found to have EIP on esophagogastroduodenoscopy (EGD). Case Description: A 57-year-old male was admitted to the hospital for acute respiratory failure secondary to influenza. His medical history was significant for type 2 diabetes mellitus, previously treated candida esophagitis, heavy smoking, and chronic alcohol consumption. Over the past six months, he reported dysphagia and a 20lb weight loss. The computed tomography scan showed a patulous esophagus with circumferential wall thickening (Fig 1). EGD demonstrated pseudo-diverticula throughout the esophagus with overlying white plaques (Fig 2,3) concerning for esophageal candidiasis. A 14-day course of fluconazole and an oral proton pump inhibitor were prescribed.1735_A Figure 1. Patulous esophagus with diffuse circumferential wall thickening1735_B Figure 2. EGD showing multiple diverticula1735_C Figure 3 No Caption available.Discussion: EIP is most commonly associated with esophageal candidiasis, but it has also been linked with diabetes mellitus, alcohol consumption, and gastroesophageal reflux disease (GERD). While EIP is a pathological diagnosis, it can be diagnosed clinically by endoscopy or esophagram. These studies usually demonstrate tiny (1-4mm), round, out-pouches along the long axis of the esophagus. These pseudodiverticula can occasionally bridge to other nearby pseudodiverticula leading to intramural tracking on esophagram. The majority of patients (75%) present with intermittent or progressive dysphagia, usually due to stricturing. However, case reports have described acute presentations with food impactions. Treatment is focused on improving symptoms and managing comorbidities. Because of its association with GERD and esophagitis, PPIs are commonly administered. For patients with candidiasis, antifungal therapy is prescribed. When esophageal strictures persist despite therapy, endoscopic dilation can be performed safely and effectively. Although EIP is rare, the clinical gastroenterologist should be aware of this unique endoscopic finding and its treatment.