S2009 Esophageal Intramural Pseudodiverticulosis and Candidiasis, Which Came First?

Abstract

INTRODUCTION: Esophageal intramural pseudodiverticulosis (EIPD) is a rare condition resulting from dilatation of excretory ducts of the esophageal deep mucosal glands. Asymptomatic by itself, symptoms are secondary to associated conditions such as gastroesophageal reflux, strictures, esophageal candidiasis and chronic esophagitis. Treatment is directed at the co-existing conditions which result in symptomatic improvement. We report two cases of EIPD with associated esophageal candidiasis. CASE DESCRIPTION/METHODS: A 55-year-old female with medical history significant for HIV underwent EGD for follow up of previous history of esophagitis. Diffuse white plaques characteristic of candida infection with multiple pseudodivertuli were seen in the distal esophagus (Figure 1). Biopsy and special stains were positive for candida hyphae. A 61-year-old female with HCV (not treated) and HIV underwent EGD for suspected upper GI bleeding. Findings included multiple pseudo-diverticuli in mid and distal esophagus (Figure 2) without gross evidence of fungal infection. Biopsy was positive for Candida. DISCUSSION: First described by Mendl in 1960, EIPD has been reported in multiple case reports. EIPD is characterized by numerous small flask shaped outpouchings within the esophageal wall seen on endoscopy. Histology shows squamous, lined, dilated excretory ducts of deep mucous esophageal glands, often surrounded by chronic inflammation. The distribution of the pseudodiverticulosis is variable with 60% of patients reporting diffuse and rest segmental (upper 14%, middle 14%, and lower 12%) distribution. The majority of patients present with intermittent or progressive dysphagia with associated stricture formation. Patients presenting with esophageal stricture require endoscopic dilation for symptom relief. Rare complications including fistula formation, perforation and mediastinitis have been reported. Acute presentations with food impactions although rare have been reported in literature. Apart from direct visualization, the pseudodiverticuli can also be identified on barium esophagogram and computed tomography. EIPD with Candidiasis has been reported approximately in 50% of patients. Despite this high rate of association it is unclear whether Candida has any role in the formation of the pseudodiverticuli. Treatment with anti-fungal therapy has been recommended even in patients with severe obstructive disease. Symptoms resolve but the persistence of pseudodiverticulosis has been reported.Figure 1Figure 2