Gastrointestinal: A rare cause of upper gastrointestinal bleeding: Epiphrenic esophageal diverticula

Abstract

An 87-year-old man presented to the Emergency Department after a syncopal event at home associated with a 3-day history of melena. This was on a background of ischemic heart disease with previous coronary artery bypass graft and recent transesophageal echocardiogram cardioversion for atrial fibrillation 10-days prior. He was commenced on apixaban during this admission and re-commenced on aspirin by his general practitioner on review post discharge. On assessment, he was hemodynamically stable, with melena noted on digital rectal examination. His laboratory results revealed a hemoglobin of 68-g/L, urea of 22.8-mmol/L, and INR of 1.7. He was commenced on intravenous pantoprazole (proton pump inhibitor), transfused with two units of packed red blood cells, and underwent a gastroduodenoscopy the following day. Upper endoscopy revealed a 2–2.5-cm diameter esophageal diverticulum (Fig.-1) just above the gastroesophageal junction (GOJ) in the right posterior-lateral wall. There was no active bleeding, but there was evidence of recent bleeding with altered blood and mild mucosal erythema in the surrounding tissue. The remainder of the endoscopy also identified two further diverticula: one in the gastric fundus within a large hiatus hernia with evidence of some altered blood and a 3rd diverticulum noted in the second portion of the duodenum with no evidence of a recent bleed. No endoscopic therapy was required at the time for hemostatic control due to the absence of active bleeding or visible high-risk stigmata. We proceeded with a computed tomography of the chest and upper abdomen (Fig.-2) as well as a barium swallow that confirmed numerous diverticula involving the GOJ (22-×-6-mm), stomach, and duodenum. Upon further history, the patient did describe having intermittent dysphagia over many years. The patient's melena resolved, and he was discharged home off aspirin with continuation of an oral proton pump inhibitor. Esophageal diverticula have a reported annual incidence of 1:500-000 per year and epiphrenic esophageal diverticula (EED) that occur within 10-cm proximal to the GOJ account for about 15% of these. EED is a very rare cause of upper gastrointestinal bleeding. As far as we are aware, there have been only a handful of these cases published to date. Although EED are largely noted incidentally, some common symptoms of presentation include dysphagia, vomiting, chest pain, and heartburn. Assessment may also involve barium swallow and computed tomography of the chest, especially for pre-operative evaluation. There are no clear guidelines or consensus as to the best course of treatment. Therapeutic interventions that have been described in previous case reports include administration of adrenaline, heater probe thermocoagulation, and hemostasis clips. If endoscopic intervention is not successful, surgical options may include diverticulectomy, myotomy, and fundoplication. Although rare, this case demonstrates that EED could potentially cause significant upper gastrointestinal bleeding and should be considered as a differential in clinical practice.