S2013 A Rare Cause of Dysphagia – Epiphrenic Esophageal Diverticulum Complicated by Complete Esophageal Obstruction

Abstract

INTRODUCTION: Epiphrenic esophageal diverticulum (EED) are a rare protrusion of the distal esophagus arising a few centimeters above the lower esophageal sphincter and is estimated to occur in 1:500,000 individuals per year. It results in motility dysfunction and typically presents as dysphagia and weight loss. Complications include upper GI bleed, esophageal carcinoma, and formation of atypical esophagorespiratory fistulas. CASE DESCRIPTION/METHODS: 66-year-old male with known history of Barrett’s esophagus and daily alcohol ingestion presented for 3 months of dysphagia with 22 kg weight loss. The initial esophagogastroduodenoscopy (EGD) demonstrated a large obstructive distal esophageal stricture for which Bougie French #60 dilation was performed at an outlying facility. Biopsy showed normal squamous mucosa. Two weeks later, dysphagia remained in which patient underwent CT chest that showed distended proximal thoracic esophagus and wall thickening with soft tissue mass involving the distal esophageal lumen consistent with obstruction; no extrinsic mass was noted (Figure 1). Laboratory workup including a complete blood count and comprehensive metabolic panel were within normal limits. Subsequent esophagram showed patulous and dilated esophagus with a large obstructive epiphrenic esophageal diverticulum (Figure 2). Esophageal ultrasound demonstrated food content within the esophageal false lumen (Figure 3). The patient subsequently had a PEG tube placed with plan to undergo traditional open transthoracic surgery with diverticulectomy and esophageal myotomy in the future. DISCUSSION: Most cases of epiphrenic esophageal diverticula are asymptomatic and do not warrant treatment though some may present with dysphagia, dyspepsia, and aspiration pneumonia. It is important to have a broad differential diagnosis including EED in patients with dysphagia. Delayed diagnosis and treatment could put patient at risk for life-threatening complications. Esophageal endoscopy is needed to rule out other dysphagia etiologies. Our case demonstrates complete esophageal obstruction leading to significant weight loss because of EED. In contrast to Zenker’s diverticulum, which occur in the proximal esophagus, EED are much rarer and occur in the distal esophagus. To contrast their rarity, EED occur at a ratio of 1:5 with that of Zenker’s. Traditionally, surgical resection is the treatment of choice. However, endoscopic techniques are being investigated.Figure 1.: CT chest shows dilated, obstructed, and irregular-shaped distal esophagus (red arrow) posterior to the pulmonary artery (PA). There is no extrinsic paraesophageal mass compression.Figure 2.: Esophagram shows epiphrenic esophageal diverticulum (red arrow) with complete distal esophageal obstruction indicates by the absence of contrast in the distal esophagus (black arrow); only an occasional trickle of contrast can be seen to transgress the distal esophagus into the fundus of the stomach. Note the proximity of the diverticulum to the cardiac silhouette.Figure 3.: Esophageal ultrasound showing food content within the esophageal false lumen at the 6 o’clock position.