Esophageal Pseudodiverticulosis: Uncommon Cause of Dysphagia in Patient with Candidiasis

Abstract

INTRODUCTION: Esophageal intramural pseudodiverticulosis (EIP) is a rare condition characterized by multiple tiny flask-shaped outpouchings of the esophageal wall. It is often associated with Gastroesophageal reflux disease (GERD) and other esophageal diseases like esophagitis, Crohn's disease, Tuberculsis, Mallory-Weiss syndrome and achalasia. Chronic alcoholism, diabetes and Candidiasis are also frequent associations. We present a case of mid-esophageal intramural pseudodiverticulosis due to a combination of GERD and Candida esophagitis. CASE: A 65 y/o male presented with progressive dysphagia and odynophagia for the past 4 years. His medical history includes GERD, HIV and HCV. No history of smoking or alcoholism. Physical exam unremarkable except for oral thrush. Labs: Normal CD4 count, CBC and CMP. Esophagogram showed outpouchings consistent with EIP. Subsequent EGD showed pseudodiverticulosis in midesophagus and a distal esophageal stricture. Biopsy was positive for Candida esophagitis. He was treated with fluconazole for 14 days and endoscopic dilatation of stricture resulting in symptomatic relief. DISCUSSION: EIP has been shown to be pathologically dilated excretory ducts of the sub mucous glands due to chronic inflammation. More common in males than females (3:2), it has bimodal peak incidence in teens and in fifth decade of life. Dysphagia is the most common presentation and esophageal stricture is present in 76-90% of cases. The characteristic finding on barium swallow is evidence of multiple flask shaped outpouchings of 1-4 mm with narrow necks communicating with esophageal lumen. EIPs are distributed diffusely in 60% of patients and segmentally in 40% (upper 14%, middle 14%, and lower 12%). Management includes treating accompanying diseases and relieving symptoms. When esophageal candidiasis or reflux esophagitis is present, medical treatment alone is sufficient. When there is an accompanied esophageal stricture, endoscopic dilatation provides symptomatic relief. Also, dilatation of the stricture has been reported to eliminate pseudodiverticula in some cases. EIP by itself is benign, but there are reports where EIP was associated with esophageal cancer. The difference between the prevalence of EIP in patients with cancer and that in patients without cancer was statistically significant (p < 0.0002). Hence, presence of EIP warrants evaluation for malignancy and periodic surveillance.Figure 1Figure 2