P0381 - A Case Series of Esophageal Intramural Pseudo-Diverticulosis

Yazan Addasi, MD¹, Avanija Buddam, MBBS², Erin Jenkins, MD², Subhash Chandra, MBBS^2
1Creighton University Medical Center, Omaha, NE; ²Creighton University, Omaha, NE

Introduction: Esophageal intramural pseudo-diverticulosis (EIP) is a rare benign disorder with unknown etiology. It was first described by Mendl et al. in 1960. The pseudodiverticula are formed due to dilation of the esophageal submucosal glands. We report 4 cases of EIP for patients complaining of dysphagia.

Case Description/Methods: A: A 31-year-old (Y.O) male who presented with longstanding dysphagia to solids (DTS), esophagogastroduodenoscopy (EGD) showed ringed esophagus, longitudinal furrows in the entire esophagus, multiple small-mouthed diverticula aligned in a linear fashion, and a small hiatal hernia (HH). Biopsy showed increased eosinophils. Proton pump inhibitor (PPI) was prescribed without improvement in endoscopic changes or eosinophil count. Esophageal Dilation (ED) resulted in dramatic mucosal tear without perforation along with significant symptomatic improvement.
B: A 53 Y.O male presented with longstanding DTS. EGD showed ringed esophagus and longitudinal furrows, along with narrow-mouthed diverticula noted in linear fashion in between the rings. Biopsy had increased eosinophilic infiltrate in the esophageal mucosa with eosinophilic esophagitis. ED resulted in significant mucosal tear without perforation and improved symptoms.
C: A 47 Y.O female with history of GERD on PPI who had DTS. EGD showed severely narrowed esophagus with rings and stricture throughout the esophagus, narrow diverticula between the rings, and a small HH. Esophagogram showed tiny diverticula in upper esophagus. ED resulted in dramatic mucosal tears. Biopsies were negative for eosinophilic esophagitis.
D: A 51 Y.O male presented with heartburn and DTS. EGD showed ringed stenosis in the lower esophagus and a small HH. Between the rings, multiple small and large mouthed diverticula were noted in a linear fashion. Esophageal biopsies showed basal cell hyperplasia with no increased eosinophils. ED was done without complication and resulted in symptomatic improvement.

Discussion: Though the underlying etiology of EIP is not clear in literature, all 4 cases in our experience had diffuse and severe esophageal stricturing, 2 patients had eosinophilic esophagitis and the other 2 patients had likely reflux strictures. Similar observations were noted in literature. Therefore, we speculate that EIP is result of stricturing instead of being a disease entity of its own. Dysphagia is the most common presenting symptom which responds to dilation. Dilation results in significant mucosal tears but full thickness perforation is rare.


Figure: Endoscopic appearance of esophageal pseudodiverticulosis.

	Endoscopic findings	Type of dysphagia	Mucosal disruption post dilation	Linear distribution of diverticula	Associated underlying condition	Hiatal hernia	Biopsy
Case A	Ringed esophagus and longitudinal furrows, in entire esophagus, along with multiple small mouth diverticula in upper and middle third of esophagus	Solid food	Significant mucosal tear without perforation	Linear	Eosinophilic esophagitis	Present	Intracellular edema as well as increased intramucosal eosinophils ( >20 eosinophil/hpf)
Case B	Ringed esophagus and longitudinal furrows, along with narrow mouth diverticula noted in linear fashion in between the rings in the upper esophagus	Solid food	Significant mucosal tear without perforation	Linear	Eosinophilic esophagitis	Absent	squamous mucosa with marked spongiosis and increased eosinophilic infiltrate (30-35 eosinophil/hpf). Superficial clustering of eosinophil as well as eosinophilic microabscesses.
Case C	Narrow caliber esophagus with rings, benign intrinsic stenosis in upper esophagus, along with multiple small mouthed diverticula noted in upper and middle third of the esophagus	Solid food	Significant mucosal tear without perforation	Uncertain	Gastroesophageal reflux disease	Present	Acute esophagitis with rare yeast forms on PAS stain consistent with candida esophagitis. No significant increase in eosinophils.
Case D	Widely patent Schatzki ring, along with small and large mouthed diverticula in the lower third of the esophagus. Mild esophagitis.	Solid food	No mucosal disruption post dilation	Linear	Gastroesophageal reflux disease	Present	Mild basal hyperplasia with no evidence of eosinophilic inflammation.

Table: Overview of clinical, endoscopic, and histologic findings of the described cases.


Disclosures:
Yazan Addasi indicated no relevant financial relationships.
Avanija Buddam indicated no relevant financial relationships.
Erin Jenkins indicated no relevant financial relationships.
Subhash Chandra indicated no relevant financial relationships.


Yazan Addasi, MD¹, Avanija Buddam, MBBS², Erin Jenkins, MD², Subhash Chandra, MBBS². P0381 - A Case Series of Esophageal Intramural Pseudo-Diverticulosis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.