Esophageal intramural pseudodiverticulosis with food impaction

Division of Gastroenterology, Centre of Therapeutic Endoscopy and Endoscopic Oncology, University of Toronto, St Michael’s Hospital, Toronto, Ontario Correspondence and reprints: Dr Norman E Marcon, St Michael’s Hospital, 16-062 Cardinal Carter Wing, 30 Bond Street, Toronto, Ontario M5B 1W8. Telephone 416-864-3092, fax 416-864-5993, e-mail Norman.marcon@utoronto.ca Received for publication June 25, 2005. Accepted July 14, 2005 T Attila, NE Marcon. Esophageal intramural pseudodiverticulosis


CASE PRESENTATION
A 57-year-old man of African descent presented to the emergency room with a food bolus impaction.The patient had been experiencing intermittent solid dysphagia for six months without any prior history of food impaction.The patient denied any heartburn, regurgitation, dyspepsia, abdominal pain and weight loss.He was not taking any prescription or over-thecounter medications.He had a history of alcohol abuse but denied smoking or ingestion of any caustic material.He had laparoscopic sigmoidectomy for stage 3 sigmoid cancer 18 months before presentation with the food impaction, for which he received six cycles of 5-fluorouracil and folinic acid therapy.A postsurgical computed tomography scan of the patient's thorax, abdomen and pelvis, with intravenous and oral contrast, was significant only for pancreatic calcifications within the head of the pancreas and a slightly irregular pancreatic duct consistent with chronic pancreatitis.Splenic vein thrombosis with multiple collaterals was noted at the splenic hilum.No mediastinal or hilar adenopathy were noted.Emergency upper endoscopy revealed a solid piece of meat at the distal esophagus, which was easily pushed into stomach.The esophageal mucosa did not have any ulceration or necrosis, but a Schatzki's ring was noted.The patient was discharged from the emergency room with daily proton pump inhibitor therapy.The patient was seen electively for a repeat upper endoscopy with dilation of the Schatzki's ring.Careful evaluation of the esophagus revealed a diffuse esophageal pit-like appearance suggestive of pseudodiverticulosis (Figure 1) and a Schatzki's ring.A tear of the ring was noted following esophageal dilation up to 36 Fr.Esophageal biopsies showed squamous epithelium without any abnormality.An esophagogram confirmed the diagnosis of pseudodiverticulosis (Figure 2).The patient was dilated to 45 Fr on another occasion.His dysphagia completely resolved with esophageal dilation and proton pump inhibitor therapy.He has been symptom free for nine months.

DISCUSSION
Esophageal intramural pseudodiverticulosis (EIPD) is an uncommon condition characterized by flask-like outpouchings with segmental or diffuse involvement of the esophagus and is frequently associated with esophageal radiological narrowing (1,2).In the largest retrospective review of esophageal radiological examinations, this condition was diagnosed in 0.15% of patients (3).EIPD occurs at any age; however, it is most commonly observed in the sixth and seventh decade of life (2).Postmortem examinations revealed that pseudodiverticula are, indeed, dilated excretory ducts of the esophageal submucosal glands (4,5).Although etiology and pathogenesis of this rare condition have been obscure, obstruction of ducts by inflammatory material, mucus and desquamated epithelium was postulated as the cause of ductal dilation (6).The presence of chronic esophageal inflammation in autopsies of patients with EIPD suggests that this condition may be a sequela of esophagitis (5).Despite esophagitis being relatively common in endoscopic practice, it is unknown why EIPD is so rare.Our patient started to have dysphagia after chemotherapy, but we have not identified any literature on the etiological correlation between chemotherapy and EIPD.EIPD has been reported with gastroesophageal reflux, strictures, webs, herpes or candida esophagitis and esophageal neoplasm (2,3,7,8).Although esophageal motility disorders, such as irregular tonic contractions, tertiary contractions and aperistalsis are commonly reported (2), the causative correlation is not clear.Dysphagia is the most common symptom, which may be acute or chronic (9,10).The most effective therapy is dilation of strictures and treatment of esophagitis.
Our knowledge of the long-term outcome of this condition is limited.On rare occasions, pseudodiverticula have disappeared, but in the majority of cases, visible pseudodiverticula persisted despite symptomatic relief (9,10).Although EIPD has been traditionally viewed as a benign condition, a retrospective review of esophagograms at Tulane University (Louisiana, USA) revealed a significantly higher prevalence of this condition in patients with esophageal carcinoma (11).
Long-term follow-up of these patients will determine the need for periodic surveillance.Peridiverticulitis is a rare complication of this benign (12,13).
In summary, the present report describes a patient with diffuse EIPD who presented with food bolus impaction due to Schatzki's ring.His dysphagia completely resolved with endoscopic dilations and acid suppression with proton pump inhibitor therapy, but his EIPD persisted.It appeared that his dysphagia was secondary to Schatzki's ring and EIPD was an incidental finding.There is likely no cause and effect relationship between both conditions, but both of them probably share a similar cause -gastroesophageal reflux disease.