S1900 Esophageal Pseudodiverticulosis Mimicking Esophageal Perforation

Abstract

INTRODUCTION: Esophageal intramural pseudodiverticulosis (EIP) is a rare benign pathology, It is attributed to the defective secretion of submucosal glands followed by the abnormal dilation of ducts and development of pseudodiverticular outpouchings. It commonly presents as dysphagia. Here we report an unusual presentation of EIP with retrosternal chest pain, mimicking esophageal perforation. CASE DESCRIPTION/METHODS: A 53-year-old female with a past medical history of COPD, hypertension, depression, and anxiety disorder was brought to the hospital from another facility with a 5-day history of retrosternal chest pain radiating to the back and mild shortness of breath. The patient complained of a 3-month history of pain on swallowing both for liquids and solids. There was a history of poor oral intake and weight loss of 5 pounds in the last 1 month. She has a long term underlying acid reflux and was not on any medications. The physical exam was within normal limits. Lab investigations including CBC and CMP were normal. CT chest showed some 2.5 cm × 2.6 cm × 8 cm lesions in the subcarinal area in the posterior mediastinum along the esophageal wall. There were some air pockets concerning possible esophageal perforation. Esopharogram was performed which showed no perforation. Esophagogastroduodenoscopy (EGD) was performed which showed candida esophagitis with the presence of multiple esophageal pseudodiverticulosis. A repeat CT chest did not reveal any esophageal mass. There was likely esophageal thickening related to Candida esophagitis with associated multiple esophageal pseudodiverticulosis. The patient was started on fluconazole with a plan of repeat EDG in 4 weeks after completing antifungal treatment. DISCUSSION: Dysphagia is considered to be a common presenting symptom in EIP. It is frequently associated with certain inflammatory and infective etiologies including esophagitis, diabetes mellitus, and gastroesophageal reflux disease. Endoscopy is considered to be the initial diagnostic test. Other investigations involving CT, esophageal contrast radiography, and histology are also performed for confirming the diagnosis. The treatment includes the management of underlying pathology. In most of the cases, strictures are formed and endoscopic dilation can alleviate the symptoms of such patients.Figure 1.: Transmural severe thickening of esophageal wall with a tiny air pocket mimicking possible micro-perforation.Figure 2.: Multiple tiny projections arising from esophageal wall consistent with esophageal pseudodiverticulosis.Figure 3.: Mutiple tiny diverticuli with submucosal bulge. Mild luminal stenosis with esophageal candidiasis.