Swallow This: A Case of Intramural Esophageal Pseudodiverticulosis Presenting With Dysphagia

Abstract

INTRODUCTION: Intramural esophageal pseudodiverticulosis is a rare cause of dysphagia in adults. The most important risk factors include chronic alcohol abuse and tobacco abuse. Diagnosis is most commonly made through esophagram, while endoscopy provides direct view of the pseudodiverticula. Though rare, this is an important cause of dysphagia to consider in patients with history of alcohol and tobacco abuse. CASE: A 62 year-old man presented to the gastrointestinal clinic with dysphagia to solids, stating that he feels solids get “stuck” above the sub clavicular notch. In particular, he complained of dysphagia to solids with most meals to pills and tough textured meats, as well as a 15-20 pound weight loss. Social history was significant for chronic daily alcohol use and smoking history of 45 pack years. An esophagram was initially performed to evaluate his dysphagia, which demonstrated multiple tiny, flask-shaped outpouchings in the esophageal mucosa consistent with esophageal pseudodiverticulosis (Figures 1 and 2). Subsequently, an esophagastroduodenoscopy was performed, demonstrating esophageal pseudodiverticulosis in the mid esophagus (Figure 3). Patient was given proton pump inhibitor therapy, and providers stressed the importance of tobacco and alcohol cessation. The patient followed up a month later with complete resolution of his symptoms.FigureFigureFigureDISCUSSION: Esophageal intramural pseudodiverticulosis is a rare cause of dysphagia. It is thought to be caused by inflammation of the submucosal glands in the esophagus, which lead to outpouchings in the esophageal wall. Chronic alcohol abuse and tobacco are the most important risk factors for the disease, present in majority of patients. Other risk factors include Candida and erosive esophagitis. Esophagram shows distinctive flask outpouching, and endoscopy provides the most direct view of the pseudodiverticula, though present in only 20% of cases. Patients may be at increased risk for esophageal carcinoma. There are currently no screening guidelines for esophageal carcinoma for patients with intramural esophageal pseudodiverticulosis. It is uncertain if there is an increased risk secondary to risk factors such as alcohol abuse and tobacco or from the pseudodiverticulosis itself. Treatment of the underlying condition is the mainstay including alcohol and tobacco cessation, proton pump inhibitor therapy, anti-fungal therapy, and dilation for those suffering from dysphagia symptoms.