Esophageal Intramural Pseudodiverticulosis / Pseudodiverticulosis intramural del esófago

Abstract A report of two cases of esophageal intramural pseudodiverticulosis, a very unusual disease, with other 240 cases reported in the entire world literature since 1960. Its etiology and pathogenesis are still not fully understood. However, it is believed that hypertrophy of the submucosal glands, with chronic inflammation, fibrosis, and consequent esophageal stenosis, causes dysphagia, which is the primary manifestation of esophageal intramural pseudodiverticulosis. The main diagnostic methods include the radiological examination of the esophagus with barium contrast (esophagogram) and esophagogastroduodenoscopy (EGD). Both reported cases were treated with endoscopic dilation, exemplifying the safety and efficacy of this therapeutic option for treating dysphagia in these individuals.

Resumen Reporte de dos casos de pseudodiverticulosis esofágica intramural, una enfermedad muy inusual, con otros 240 casos reportados en toda la literatura mundial desde 1960. Su etiología y patogenia aún no se conocen completamente; sin embargo, se cree que existe una hipertrofia de las glándulas submucosas, con inflamación crónica, fibrosis y consecuente estenosis esofágica, lo que provoca disfagia, que es la principal manifestación de la pseudodiverticulosis esofágica intramural. El examen radiológico del esófago con contraste de bario (esofagograma) y la endoscopia digestiva alta (EDA) son los principales métodos de diagnóstico. Ambos casos reportados se trataron con dilatación endoscópica, lo que ejemplifica la seguridad y eficacia de dicha opción terapéutica para el tratamiento de la disfagia en estos individuos.

Clinical and endoscopic characteristics of diffuse esophageal intramural pseudo-diverticulosis.

INTRODUCTION: With 250 published cases worldwide, diffuse esophageal intramural pseudo-diverticulosis (DEIPD) is a poorly understood disease. The aim of this study was to determine the prevalence of DEIPD in our own population, identify risk factors and clinical symptoms, and characterize its typical endoscopic signs. METHODS: Retrospective search in our center's endoscopic and clinical database. Reviewing of all cases by re-examining stored endoscopic photographs. Reviewing of all cases regarding age, sex, risk factors, comorbidities, histology, and clinical symptoms. RESULTS: In a population of 150.000 we found 21 cases of DEIPD. Mean age was 56 ± 10 years. 86% were males, 76% had alcohol abuse, 57% had nicotine abuse, 38% had arteriosclerosis, 33% had COPD, 29% had malignancies, 24% had liver cirrhosis, 19% had impaired kidney function, and 15% had diabetes. Dysphagia was present in 62% and food bolus impaction (single or repeated) in 48%. Endoscopically, 95% of patients had multiple (> 4), small (0.25-2.5 mm) pseudodiverticle openings in the esophageal wall. In 62%, openings were aligned longitudinally. 86% showed edematous swelling of mucosa ("frosted glass look"), 76% showed a fine-grained pattern of small (10-100 µm) red dots ("faux uni pattern"), and 76% had a rigid, narrow lumen with multiple rings ("trachealization"). CONCLUSION: With a prevalence of approximately 5 to 50/100.000, DEIPD may be more frequent than previously estimated. It preferably affects middle-aged male alcoholics. Key symptoms are chronic dysphagia and food impaction. Typical endoscopic findings are multiple, small, longitudinally aligned pseudodiverticle openings, frosted glass look, faux uni pattern, and trachealization of the esophagus.

A rare cause of dysphagia due to esophageal intramural pseudodiverticulosis: a case report and review of literature.

BACKGROUND: Esophageal intramural pseudodiverticulosis is an uncommon, idiopathic disorder characterized by multiple small outpouchings protruding from the esophageal lumen. Esophageal intramural pseudodiverticulosis is associated with conditions such as gastroesophageal reflux disease and diabetes mellitus, as well as emergent complications including pneumomediastinum. The most common presenting symptom is dysphagia with associated esophageal stricture formation. While the pathogenesis of EIP has yet to be determined, it is important to bring awareness to this unique disease with distinctive diagnostic findings and treatment options. CASE PRESENTATION: In this case, we present a 62-year-old woman who suffered from dysphagia, an inability to tolerate a regular diet, and unintentional weight loss for several years prior to her diagnoses. She was diagnosed by esophagram and esophagogastroduodenoscopy to have esophageal intramural pseudodiverticulosis, complicated by severe stricture formation. Following treatment with sequential dilatation and maintenance H2-blocker therapy, she achieved significant symptomatic improvement. CONCLUSIONS: This case highlights the importance of accurate identification and treatment of an uncommon cause of dysphagia, esophageal intramural pseudodiverticulosis. Treatment includes dilatational therapy, as successfully demonstrated in our patient. Furthermore, treatment is focused on optimizing medical management, as demonstrated in our patient with the addition of an H2-blocker for GERD, or addressing potentially serious underlying causes, such as carcinoma, with surgery.

Pseudodiverticulosis: a rare presentation of eosinophilic esophagitis.

Esophageal pseudodiverticulosis is a rare endoscopic finding in eosinophilic esophagitis. We report a case of a 32-year-old male who presented with dysphagia and gastroesophageal reflux disease and was found to have esophageal pseudodiveritcula along with esophageal rings. The patient was subsequently treated with endoscopic balloon dilation and a diagnosis of eosinophilic esophagitis (EoE) with pseudodiverticulosis was made based upon the endoscopic and biopsy findings. This case provides evidence of the unusual finding of pseudodiverticulosis associated with EoE and further understanding of its pathogenesis is required.

Candida albicans: a cause or a consequence of esophageal intramural pseudo-diverticulosis.

Esophageal intramural pseudo-diverticulosis is a rare disease of unknown etiology. It is characterized by multiple pseudodiverticula with segmental or diffuse involvement of the esophagus. We report, the case of a 78-year-old male who suffered from severe dysphagia. Diagnosis of esophageal intramural pseudo-diverticulosis was based on endoscopic and radiologic explorations. Histological analysis of esophageal mucosal biopsies has shown the presence of candida albicans. Antifungal treatment leads to spectacular improvement of dysphasia. Subsequently, the patient presented a cardio-respiratory failure and died despite adequate treatment.

Esophageal intramural pseudodiverticulosis in a patient with food bolus impaction / Pseudodiverticulosis intramural esofágica en un paciente con impactación de bolo alimentario

Esophageal intramural pseudodiverticulosis is an uncommon esophageal benign disease. The typical finding during endoscopy is the presence of numerous pinhead-sized outpouchings along the esophageal wall. We reported a case of food bolus impaction secondary to esophageal intramural pseudodiverticulosis. A 67-year-old man presented with sudden-onset dysphagia. Multiple tiny orifices were revealed during upper endoscopy. In addition, there were an impacted food bolus and an esophageal web. The patient was treated with balloon dilatation and proton pump inhibitors. As a result the symptoms disappeared completely. Esophageal intramural pseudodiverticulosis is a rare cause of food bolus impaction and its treatment is directed towards the underlying associated conditions as well as the resolution of complications.

La pseudodiverticulosis intramural esofágica es una enfermedad benigna del esófago poco común. El hallazgo típico durante la endoscopia es la presencia de numerosos sáculos del tamaño de una cabeza de alfiler a lo largo de la pared esofágica. Reportamos un caso de impactación de bolo alimentario secundario a pseudodiverticulosis esofágica intramural. Un hombre de 67 años presentó disfagia de aparición repentina. Se encontraron múltiples orificios pequeños en la endoscopia superior. Además, hubo un bolo alimentario impactado y una red esofágica. El paciente fue tratado con dilatación con balón e inhibidores de la bomba de protones. Como resultado, los síntomas desaparecieron por completo. La pseudodiverticulosis intramural esofágica es una causa rara de impactación del bolo alimentario y su tratamiento se dirige a las condiciones asociadas subyacentes, así como a la resolución de complicaciones.

Esophageal intramural pseudodiverticulosis in a patient with food bolus impaction.

Esophageal intramural pseudodiverticulosis is an uncommon esophageal benign disease. The typical finding during endoscopy is the presence of numerous pinhead-sized outpouchings along the esophageal wall. We reported a case of food bolus impaction secondary to esophageal intramural pseudodiverticulosis. A 67-year-old man presented with sudden-onset dysphagia. Multiple tiny orifices were revealed during upper endoscopy. In addition, there were an impacted food bolus and an esophageal web. The patient was treated with balloon dilatation and proton pump inhibitors. As a result the symptoms disappeared completely. Esophageal intramural pseudodiverticulosis is a rare cause of food bolus impaction and its treatment is directed towards the underlying associated conditions as well as the resolution of complications.

Pneumomediastinum as a complication of esophageal intramural pseudodiverticulosis.

Dysphagia is a common complaint of patients seen at the outpatient clinic as well as at the emergency room. We report esophageal intramural pseudodiverticulosis (EIPD) as a cause of dysphagia that is less known by physicians and it is rarely described in the literature. EIPD is characterized by multiple, segmental or diffuse, flask-like outpouchings in the esophageal wall corresponding to dilated and inflamed excretory ducts of the submucosal esophageal glands. The underlying etiology remains unclear. Esophageal strictures, esophageal candidiasis and gastroesophageal reflux disease are often associated. The diagnosis can be made by upper gastrointestinal endoscopy, but barium esophagography is the modality of choice. Complications of EIPD are rare and include broncho-esophageal and esophagomediastinal fistula, pleural and pericardial effusion, abscesses, gastrointestinal bleeding from a web-like stenosis or esophageal perforation with pneumomediastinum. The treatment for EIPD should be directed towards treating underlying associated conditions and relieving symptoms rather than the pseudodiverticulosis itself.

Disfagia por seudodiverticulosis esofágica intramural: inusual hallazgo endoscópico / Dysphagia caused by intramural oesophageal pseudodiverticulosis: An unusual endoscopic finding

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Imágenes en divertículos del tubo digestivo: localizaciones infrecuentes. serie de casos / Imaging in infrequent digestive diverticula: case series

Los divertículos se pueden localizar en todo el tubo digestivo (TD): esófago, estómago, duodeno, yeyuno, íleon, apéndice, colon. Son infrecuentes, salvo en colon. Sus manifestaciones clínicas son inespecíficas, con difícil diagnóstico y mayor riesgo de complicaciones. Se presenta una serie de divertículos digestivos atípicos, mostrando las características imagenológicas multimodalidad y describir los hallazgos claves. Es una revisión retrospectiva en el archivo computacional de nuestra institución. Selección de casos de divertículos de presentación inhabitual por sus características, localización u origen. En esófago los divertículos de Zenker y Killian-Jamieson. En estómago los divertículos gástricos infrecuentes. Los divertículos en intestino delgado tienen baja prevalencia, el más frecuente en duodeno. Los divertículos colónicos pueden tener una localización o presentación atípica. Los divertículos apendiculares y Meckel presentan baja prevalencia. Los divertículos digestivos son infrecuentes, excepto los colónicos. El radiólogo debe estar familiarizado con las diferentes ubicaciones de ellos, para reconocerlos y poder diagnosticarlos.

Diverticula may occur in any segment of the digestive tract: esophagus, stomach, duodenum, jejunum, ileum, appendix, and colon. Its clinical manifestations are nonspecifi which may turn diffiult an early diagnosis, leading to a higher risk of complications. We present a cases serie of atypical digestive diverticula and to describe the fidings on the different imaging techniques. We performed a retrospective review on the imaging computer archives of our institution. The atypical diverticula were selected. Zenker and Killian-Jamieson's diverticulums in esophagus. In stomach ocasionally gastric diverticula. Diverticula in small intestine have a low prevalence, the most common location is duodenum. Colonic diverticula may present a atypical location or presentation. The appendicular and Meckel diverticuli are uncommon. The digestive diverticula are uncommon, except the colonic ones. The radiologist must be familiar with it's different locations in order to be able to recognize it and diagnose it properly.

[Surgical Repair of Kommerell's Diverticulum with Right Sided Aortic Arch;Report of a Case].

A 54-year-old woman was referred for assessment of dysphagia and extrinsic compression of the esophagus detected by upper gastrointestinal endoscopy. Computed tomography revealed the rightsided aortic arch with mirror image branching and Kommerell's diverticulum. To relieve the esophageal compression, surgical intervention was indicated. Descending aortic replacement with a Dacron graft was performed through right thoracotomy under partial cardiopulmonary bypass. The patient was discharged without any complication, and her dysphagia disappeared.

Diverticulo de esofago médio: relato de caso / Middle esophageal diverticulum: a case report

Introdução:Divertículos esofagianos são alterações esofá-gicas raras e podem ser classificados em proximais, médios ou distais, de acordo com a localização. Podem ser de pulsão ou tração e verdadeiro ou falso. Na dependência do tamanho do divertículo e da concomitância de doença associada, po-dem causar disfagia, regurgitação, mau hálito, rouquidão ou pneumopatias, podendo ter indicação de ressecção cirúrgica. O diagnóstico é suspeitado pela história clínica e confirmado pelo exame radiológico contrastado e pela endoscopia diges-tiva alta. Objetivo: Relatar o caso raro de uma paciente com divertículo de esôfago médio. Materiais e Métodos: Revisão do prontuário, registro fotográfico dos métodos diagnósticos e revisão da literatura. Resultados: Paciente feminina, 61 anos, encaminhada ao ambulatório do hospital de base de São José do Rio Preto, com queixa de disfagia progressiva para alimentos sólidos aproximadamente há cinco anos, associado à odinofagia, eructação intensa e perda ponderal nesse período de 10 quilos. A endoscopia digestiva alta, mostrou divertículo no terço médio do esôfago, 25 cm da arcada dentária supe-rior, com óstio de 3-4 cm de diâmetro e 3 cm de profundidade. A tomografia computadorizada de tórax confirmou a presen-ça do divertículo de esôfago em terço médio do esôfago, sem outros achados que justificassem sua presença. A paciente foi submetida à videotoracoscopia com ressecção do divertículo sem intercorrências. Atualmente, a paciente apresenta-se as-sintomática no acompanhamento clínico. Conclusão: Embora seja considerada uma alteração esofágica rara, os divertículos esofagianos, devem sempre ser considerados como diagnósti-co diferencial. Especialmente em casos de disfagia, halitose e enfermidades respiratórias por broncoaspiração. Em casos de pacientes sintomáticos e com dificuldade no tratamento clinico, a melhor opção terapêutica é a cirurgia com a excisão local do divertículo via toracotomia ou toracoscopia.

Introduction:Esophageal diverticula are rare conditions of the esophagus and can be classified according to their location in proximal, middle, or distal. Further categorization relates to presumed etiology, namely traction vs pulsion, true or false. Depending on the size of the diverticulum and the concomitance of associated disease, it can cause dysphagia, regurgitation, bad breath, hoarseness or pneumopathies. Thus, symptomatic patients are eligible surgical resection. The diagnosis is suspected by clinical history and confirmed by contrast radiological examination and upper digestive endoscopy. Objective: Present the case of a patient with middle esophageal diverticulum. Materials and Methods: We carried out a review of medical records, photographic record of diagnostic methods, and review from the literature. Results: A 61-year-old female patient was referred to the outpatient clinic at a teaching hospital (Hospital de Base), located in the city the São José do Rio Preto, inland of São Paulo State due to progressive complaints of dysphagia for solid foods for about 5 years, associated with odynophagia and severe eructation. She had a 10 kg weight loss in this period. Upper digestive endoscopy showed a diverticulum in the middle third of the esophagus, 25 cm from the dental arcade, with an ostium diameter of 3-4 cm and depth of 3 cm. A chest computed tomography confirmed the presence of an esophageal diverticulum in the middle third of the esophagus, in addition to other findings that justify its presence. She underwent video-assisted thoracoscopy with diverticulum resection without further complications. Currently, she is asymptomatic in clinical follow-up. Conclusion: Although it is considered a rare outgrowth, esophageal diverticula should always be considered as a differential diagnosis, especially in cases of dysphagia, halitosis, and respiratory diseases due to bronchoaspiration. In cases of symptomatic patients with difficulty to undergo clinical treatment, the best therapeutic option is a surgery with local excision of the diverticulum via thoracotomy or thoracoscopy.

Disfagia secundaria a seudodiverticulosis esofágica intramural / Dysphagia secondary to esophageal intramural pseudodiverticulosis

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