Esophageal intramural pseudodiverticulosis, an unusual cause of dysphagia: report of a case

Abstract

lacking, yet it is thought to be associated with a chronic inflammatory process [1]. Patients present with progressive dysphagia to solids and chest discomfort, though, the condition remains mostly asymptomatic. The characteristic endoscopic findings of multiple orifices of the esophageal mucosa are only seen in 20 % of the cases, making the condition easily missed [2]. Herein, we report a case of EIP in a patient with a 9-month history of dysphagia, with typical endoscopic findings and successful response to oral antifungal agents alone. Case reportA 66-year-old man presented in poor general condition with a nine-month history of progressive dysphagia for solids. In the past year he noted a weight loss of 25 kg. The patient´s medical history was significant for chronic alcohol and nicotine abuse, without any additional comorbidities. Laboratory testing showed leukocytosis and an abnormal gamma-GT value. Candida-specific IgG and IgA serum antibody titers were also found to be elevated (45 and 29 U/mL, respectively). A barium esophagogram demonstrated small diverticulum-like sacculations extending along the proximal and distal third of the esophagus (Fig. 1). Upper endoscopy showed several small orifices and white, plaque-like lesions on the mucosal surface of the esophagus, without any significant strictures (Figs. 2, 3). The thoracic computed tomography showed a long segment of esophageal wall thickening. Histopathologic findings of the endoscopic biopsy specimens were consistent with EIP (chronic granulomatous inflammation in the Tunica propria, Fig. 4) and Candida-esophagitis (positive PAS staining). Medical treatment with oral Amphotericin-B (10 mg lozenges, four Abstract Esophageal intramural pseudodiverticulosis (EIP) is a rare disorder of unknown etiology. On histopathology, it is characterized by dilation of the submucosal esophageal glands. The main presenting symptom is dysphagia to solid foods. Most patients diagnosed with EIP also have a history of diabetes mellitus, gastroesophageal reflux disease, esophageal candidiasis, or chronic alcohol and nicotine abuse. Yet, the exact pathophysiologic mechanism still remains unclear. The most frequent complication, occurring in 80 % of the patients, is esophageal stricture. The mainstay of therapy is directed towards symptom relief with administration of proton pump inhibitors (PPIs) combined with antifungals and/or endoscopic dilations, if necessary. We report a case of a 69-year-old man who presented with a 9-month history of progressive dysphagia and a 25 kg-weight loss, with typical endoscopic findings of EIP and successful response to medical therapy with oral antifungals alone.