Swiss Cheese Esophagus: A Case of Esophageal Intramural Pseudodiverticulosis

Abstract

Diverticula can be seen throughout the gastrointestinal tract including the Esophagus. Esophageal Intramural Pseudodiverticulosis (EIPD) is a rare condition characterized by the presence of multiple pinhead-sized outpouchings of the esophageal wall, giving the esophagus the appearance of Swiss cheese on endoscopy. We present a case of EIPD in a patient with eosinophilic esophagitis (EoE). To our knowledge, this is the first case describing EIP with concomitant EoE. A 72 year old Caucasian male presents to a gastroenterology clinic for evaluation of dysphagia. He underwent endoscopy as part of his evaluation, which revealed multiple esophageal diverticula as well as distal esophageal strictures. The patient underwent successful esophageal stricture dilation and was advised to follow up for a repeat endoscopy. He followed with another gastroenterologist for the next 3 years where he was diagnosed with Eosinophilic Esophagitis (EoE). He was treated with oral budesonide slurry but continued to have recurrent dysphagia. He presented with a complaint of “macaroni stuck” in his throat. The food bolus passed spontaneously and on endoscopy he had multiple esophageal rings as well as pseudodiverticulosis. The patient underwent Savary dilation, followed by multiple repeat stricture dilatation sessions in the following months. He subsequently had complete resolution of his dysphagia, while on budesonide, and had a satisfactory endoscopic appearance on the most recent endoscopy, except for the pseudodiverticulosis. EIPD was first described in 1960 by the British Institute of Radiology. To date a little over 200 cases of EIP have been described in the literature. Unlike colonic diverticula, the exact mechanism by which EIPD forms is unclear. It seems, however, to be affected by chronic inflammation whereby the structural integrity of the esophageal lining, especially at the excretory ducts of the submucosal glands, is compromised leading to the formation of diverticula. This rare entity represents a unique challenge, especially in the presence of other concomitant conditions. In our patient, both EoE and EIPD can lead to dysphagia and stricture formation. This raises an interesting question: Are the strictures a result of EIPD or EoE or both? Also, if EIPD is associated with chronic inflammatory states then why is it not more commonly seen with conditions such as reflux esophagitis?Figure 1