P5019 - Esophageal Intramural Pseudodiverticulosis: A Rare Cause of Esophageal Dysphagia

Miles Graves, MD, Duane Deivert, DO, FACG
Geisinger Wyoming Valley Medical Center, Wilkes-Barre, PA

Introduction: Esophageal intramural pseudodiverticulosis (EIPD) is a rare benign disease of the esophagus in which abnormal dilations of esophageal submucosal mucinous glands appear as multiple outpouchings. It was first described in 1960 and only 200-300 cases have since been reported. We present a case of EIPD in a patient who presented with recurrent food impaction.

Case Description/

Methods: A 50-year-old male with a history of 6 prior episodes of esophageal food impactions and history of esophageal stricture presented with symptoms of esophageal obstruction. EGD demonstrated an impacted food bolus in the upper 3rd of the esophagus which was removed, revealing narrowing of the proximal esophagus with congested mucosa, diffuse exudates and multiple possible sinus tracts. Esophageal dilation was performed and reexamination demonstrated mucosal tears without evidence of perforation. Due to post-procedure chest pain, an esophagram was performed demonstrating EIPD of the thoracic esophagus and esophageal mucosal tears in three areas without evidence of full-thickness injury. Patient was discharged on PPI therapy. Biopsies demonstrated severe chronic, mildly active esophagitis in the distal and mid esophagus and severe active esophagitis with presence of fungal elements in the proximal esophagus. Fluconazole was then prescribed.

Discussion: The pathophysiology of EIPD is unclear. Two postulated mechanisms are chronic inflammation resulting in obstruction of excretory ducts and chronic irritation of the esophagus leading to fibrosis of the submucosa. EIPD exhibits a bimodal distribution with peaks in the early teenage years and the 6th to 7th decades in adults and is more common in genetic males. Patients typically experience dysphagia due to concurrent development of esophageal strictures. EIPD has been associated with systemic inflammatory diseases, gastroesophageal reflux disease, esophageal candidiasis, alcohol use, tobacco use, diabetes mellitus, HIV, Mallory-Weiss syndrome, Crohn's disease, and corrosive esophageal injury. Abnormalities of esophageal motility including achalasia, hypercontractile esophagus, uncoordinated peristalsis, and hypoperistalsis have also been associated with EIPD. Barium esophagram is the preferred diagnostic imaging for EIPD and is characterized by 1-4 mm flask shaped diverticula. Treatment of EIPD consists of anti-fungal therapy if evidence of candidiasis is appreciated, acid-suppression with proton pump inhibitors, and endoscopic dilation if strictures are present.


Figure: 1) Endoscopic image with presence of food bolus as well as diverticula consistent with esophageal intramural pseudodiverticulosis.
2-3) Endoscopic image obtained after extraction of food bolus with numerous diverticula as well as evidence of esophageal stenosis.
4) Endoscopic image obtained after dilation of esophageal stenosis up to 12 mm with multiple mucosal tears noted without evidence of perforation.


Figure: Esophagram demonstrating findings consistent with esophageal intramural pseudodiverticulosis of the upper most thoracic esophagus.

Disclosures:
Miles Graves indicated no relevant financial relationships.
Duane Deivert: Amgen Inc – Stock-publicly held company(excluding mutual/index funds). BioLife Sciences – Stock-publicly held company(excluding mutual/index funds). BioNTech – Stock-publicly held company(excluding mutual/index funds). Eli Lilly – Stock-publicly held company(excluding mutual/index funds). Exact Sciences – Stock-publicly held company(excluding mutual/index funds). Finch Therapeutics – Stock-publicly held company(excluding mutual/index funds). Gilead Sciences – Stock-publicly held company(excluding mutual/index funds). Guardant Health – Stock-publicly held company(excluding mutual/index funds). Madrigal Pharmaceuticals – Stock-publicly held company(excluding mutual/index funds). Medtronic – Stock-publicly held company(excluding mutual/index funds). Merck & Co – Stock-publicly held company(excluding mutual/index funds). Moderna – Stock-publicly held company(excluding mutual/index funds). Novo Nordisk – Stock-publicly held company(excluding mutual/index funds). Pfizer – Stock-publicly held company(excluding mutual/index funds). Regeneron – Stock-publicly held company(excluding mutual/index funds). Seres Therapeutics – Stock-publicly held company(excluding mutual/index funds). Structure Therapeutics – Stock-publicly held company(excluding mutual/index funds). Teladoc Health – Stock-publicly held company(excluding mutual/index funds). Thermo Fisher Scientific – Stock-publicly held company(excluding mutual/index funds). Viking Therapeutics – Stock-publicly held company(excluding mutual/index funds).

Miles Graves, MD, Duane Deivert, DO, FACG. P5019 - Esophageal Intramural Pseudodiverticulosis: A Rare Cause of Esophageal Dysphagia, ACG 2025 Annual Scientific Meeting Abstracts. Phoenix, AZ: American College of Gastroenterology.