Esophageal Intramural Pseudodiverticulosis and Concomitant Eosinophilic Esophagitis: A Case Series.

Background. Esophageal intramural pseudodiverticulosis (EIPD) is an idiopathic benign chronic disease characterized by flask-like outpouchings of the esophageal wall. It is unknown whether there is a genuine association between EIPD and eosinophilic esophagitis (EoE). Aims. To investigate a possible relationship between EIPD and EoE. Methods. Patients with radiographic or endoscopic evidence of pseudodiverticulosis were identified from the database at a single academic center. Cases were analyzed in three areas: clinical information, endoscopic findings, and course. Results. Sixteen cases of esophageal pseudodiverticulosis were identified. Five patients had histologic evidence of eosinophilic esophagitis. Patients with EoE had pseudodiverticula in the mid-to-distal esophagus while those with EIPD had pseudodiverticula predominantly in the proximal esophagus (p < 0.001). EoE with pseudodiverticulosis occurred in younger patients (p < 0.019). Food bolus obstructions were more common in patients with EoE and pseudodiverticulosis than in EIPD (p < 0.034). Conclusions. This is the first case series supporting a potential association between EoE and pseudodiverticulosis. We also identify characteristic features of pseudodiverticulosis that may raise clinical suspicion of underlying eosinophilic esophagitis.

Esophageal intramural pseudodiverticulosis of the residual esophagus after esophagectomy for esophageal cancer.

A 91-year-old man was referred to our hospital with intermittent dysphagia. He had undergone esophagectomy for esophageal cancer (T3N2M0 Stage III) 11 years earlier. Endoscopic examination revealed an anastomotic stricture; signs of inflammation, including redness, erosion, edema, bleeding, friability, and exudate with white plaques; and multiple depressions in the residual esophagus. Radiographical examination revealed numerous fine, gastrografin-filled projections and an anastomotic stricture. Biopsy specimens from the area of the anastomotic stricture revealed inflammatory changes without signs of malignancy. Candida glabrata was detected with a culture test of the biopsy specimens. The stricture was diagnosed as a benign stricture that was caused by esophageal intramural pseudodiverticulosis. Accordingly, endoscopic balloon dilatation was performed and anti-fungal therapy was started in the hospital. Seven weeks later, endoscopic examination revealed improvement in the mucosal inflammation; only the pseudodiverticulosis remained. Consequently, the patient was discharged. At the latest follow-up, the patient was symptom-free and the pseudodiverticulosis remained in the residual esophagus without any signs of stricture or inflammation.

Long-term follow-up after dilation in symptomatic esophageal intramural pseudodiverticulosis: an observational study in 22 cases.

Endoscopic bougienage seems to be the most effective therapy for dysphagia in esophageal intramural pseudodiverticulosis (EIPD), but nothing is known about the long-term success of this treatment option. This report presents long-term results for 21 of 22 patients with EIPD who were treated with bougienage. A total of 103 sessions of bougienage up to a diameter of 18 mm were performed, without major complications and with 100 % clinical success. During follow-up, symptom recurrence with further bougienage occurred in 12 /21 patients (57 %), who had variable symptom-free intervals (range 1.5 - 96 months). Symptom recurrence was associated with concomitant reflux esophagitis. Although this series demonstrates that bougienage is an effective method for relieving dysphagia in EIPD, the long-term effectiveness is limited.

Esophageal intramural pseudodiverticulosis: endoscopic diagnosis and therapy.

Esophageal intramural pseudodiverticulosis is a rare disease that may lead to esophageal stenosis and dysphagia. The aim of the study was to evaluate the endoscopic diagnosis, treatment and clinical course of intramural pseudodiverticulosis. We retrospectively studied endoscopic criteria of intramural pseudodiverticulitis, associated diseases, and the clinical course, particularly in patients with dysphagia because of esophageal stenosis in a period from 2002 to 2012. In 23 patients, the diagnosis was made according to endoscopic criteria. As risk factors, alcohol and tobacco consumption were present in all patients. Concomitant candida infection was present in six (26%) patients. In 12 (52%) patients esophageal stenosis was present, which was localized in the upper half of the esophagus. In 11 patients bougienage has been performed with excellent improvement of the dysphagia score from 3.7 to 1.3 (P = 0.002). However, dysphagia was recurrent in four patients with need for repeated bougienage. About half of the patients with intramural pseudodiverticulosis present with stenosis of the esophagus at the time of diagnosis. In patients with proximal esophageal stenosis and a typical risk constellation, intramural pseudodiverticulosis should be suspected. Treatment of stenosis with bougienage is effective to resolve dysphagia, but repeated bougienage may be necessary.

Management of epiphrenic diverticula.

Epiphrenic diverticula are very rarely seen and are often associated with achalasia, esophageal body dysmotility, and a high resting lower esophageal sphincter pressure. The aim of this study was to evaluate the different treatment options for patients with epiphrenic diverticula. Patients with an epiphrenic diverticulum were divided into two treatment groups: surgical and nonsurgical. Retrospective chart review was performed, and a symptom questionnaire was created. There were six patients in the nonsurgical group and 11 patients in the surgical group. The mean follow-up was 26.4 months. Ten patients had a laparoscopic operation performed. One patient was operated on thoracoscopically and had to be converted to a thoracotomy. Two diverticula were inverted with good results. There was one postoperative esophageal leak where no myotomy was added. An empyema developed in another patient at 4 weeks after surgery. One patient, in whom no antireflux procedure was performed, reported postoperative heartburn. Patients in the nonsurgical group had smaller diverticula, were not good candidates for surgery, or were asymptomatic. Esophageal diverticula are very rarely seen. Asymptomatic patients may not require therapy. If surgery is performed and the diverticulum is large, it should be removed. The laparoscopic approach is the surgical treatment of choice. A long myotomy and an antireflux procedure should be added to avoid esophageal leakage at the line of repair and gastroesophageal reflux.

[Therapy of esophageal diverticula]. / Therapie von Osophagusdivertikeln.

Diverticula of the esophagus can be divided into two categories. Pulsion diverticula result from an increased pressure gradient through the upper esophageal sphincter resulting in herniation of the mucosa through a weak point of the muscle layer. There are two types: hypopharynx (Zenker) diverticulum and epiphrenic diverticulum. Traction diverticula result from inflammatory reactions in neighboring lymph nodes or as a result of embryonic malformation and are composed of all layers of the esophageal wall. The presence of a Zenker diverticulum in a symptomatic patient represents always an indication for surgical therapy. A successful procedure contains a diverticulectomy combined with cervical myotomy. For the treatment of epiphrenic diverticula the underlying motility disorder, determined by preoperative manometry, plays a crucial role in the length of the myotomy. In order to prevent postoperative reflux a partial fundoplication should be added. Independent of location or size surgical therapy of diverticula of the esophagus has a success rate of more than 90 percent.

New look at epiphrenic diverticula.

Twenty-five patients with epiphrenica diverticula were studied to clarify the mechanism for esophageal regurgitation and to evaluate methods of treatment. Esophagogastroduodenoscopy, esophageal motility, and cineradiographic studies were performed. With probes in the tubular esophagus and diverticula of two patients, motility and cineradiographic studies were performed simultaneously to correlate symptoms and pressure changes with movement of diverticular and esophageal contents. Nineteen patients were operated, and six relatively asymptomatic patients were not. There was no operative mortality, and the one esophageal fistula that occurred healed spontaneously. Results were excellent or good in 10 operated patients followed long term after resection or imbrication of the diverticula. Eight patients did not undergo myotomy. Results in four of these patients followed long term were excellent. Retrograde movement of diverticular contents into the esophagus depends on pouch volume and a pressure gradient between the pouch and the tubular esophagus after an esophageal contraction wave in the tubular esophagus has dissipated. The height of esophageal reflux and resulting symptoms depend on these factors and the lower esophageal sphincter pressure (LESP). Asymptomatic patients with an epiphrenic diverticulum do not require operation. Resection or imbrication of a diverticulum are the operative methods of treatment. We prefer the abdominal approach when this is possible. Myotomy in contraindicated when gastroesophageal reflux exists or the LESP is below normal.

Esophageal rings, webs, and diverticula.

Rings, webs, and diverticula are among the most common anatomic anomalies of the esophagus. Although these structural lesions are often asymptomatic, patients can develop significant problems with dysphagia, regurgitation, and aspiration. This article discusses the epidemiology, pathogenesis, diagnosis, and therapy of esophageal rings, webs, and diverticula with emphasis on the clinical, diagnostic, and therapeutic strategies involved in caring for patients with these conditions.

[Generalized weakness in pre-existing achalasia]. / Allgemeine Schwäche bei vorbestehender Achalasie.

Several endoscopic dilatations of the distal esophagus had been performed on this 77 year old woman with achalasia and secondary epiphrenic diverticulum. At present, swallowing was not essentially hampered and the body weight was stable. She was admitted for general weakness and a fall. The investigations revealed a traumatic pelvic fracture, as well as microcytic hypochromic anemia and marked hypoproteinemia. Endoscopy of the upper gastrointestinal tract showed an extreme inflammatory reaction of the mucosa. It was postulated that bacterial overgrowth had spread from the esophageal diverticulum to the upper intestinal tract and induced infectious anemia and protein-loosing enteropathy. Anemia and hypoproteinemia responded well to a treatment with cotrimotazole but relapsed after discontinuation of the antibiotics.