Video Endoscopic Sequence 1 of 18.

Esophageal intramural pseudodiverticulosis

This is the case of a 72 year-old, who presented with one month with dysphagia and certain nonspecific discomfort in the neck, three months previous, underwent a, hysterectomy due to a endometrial carcinoma with a subsequent radiotherapy with linear accelerator in the pelvic region.

Esophageal intramucosal pseudodiverticulosis is a rare condition wherein the wall of the esophagus develops numerous small outpouchings (pseudodiverticulae). Individuals with the condition typically develop difficulty swallowing. The outpouchings represent the ducts of submucosal glands of the esophagus. It typically affects individuals in their sixth and seventh decades of life. While it is associated with certain chronic conditions, particularly alcoholism, diabetes and gastroesophageal reflux disease, the cause of the condition is unknown. Treatment involves medications to treat concomitant conditions such as reflux (such as proton pump inhibitors) and esophageal spasm, and dilation of strictures in the esophagus.

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Video Endoscopic Sequence 2 of 18.

Esophageal intramural pseudodiverticulosis

As the condition involves alterations in the wall of the esophagus and reduction in the calibre of the esophagus, the symptoms of esophageal intramucosal pseudodiverticulosis are primarily related to swallowing. Difficulty swallowing solids is a typical symptom. In extreme cases, food may become impacted in the esophagus. Some individuals may have bleeding in the esophagus, manifesting as vomiting of blood or as melena stools. With the reduction of oral intake due to difficulty swallowing, affected individuals usually lose weight.

Pseudodiverticular rupture with mediastinitis has been reported but is very rare.

Video Endoscopic Sequence 3 of 18.

Video Clips of Esophageal intramural pseudodiverticulosis

The cause of esophageal intramucosal pseudodiverticulosis is uncertain. It has been hypothesized that the pseudodiverticulae are not a primary phenomenon, but rather are secondary to a chronic irritant to the esophagus, or to accentuation in the movement of the esophagus (hypermotility). Both of these factors lead to obstruction or compression of the subucosal ducts of the esophagus, leading to the formation of the pseudodiverticulae. Autopsy specimens of individuals with esophageal intramucosal pseudodiverticulosis have confirmed that the flask-like openings are indeed dilated submucosal glands. The condition is associated with alcohol abuse, diabetes mellitus, and gastroesophageal reflux disease.

Video Endoscopic Sequence 4 of 18.

Video Clips of Esophageal intramural pseudodiverticulosis

Esophageal intramucosal pseudodiverticulosis is typically diagnosed at the time of endoscopy of the esophagus. Endoscopy shows evidence of the pseudodiverticulae, which are typically numerous, appear like pits in the wall, and may be preferentially located in the upper esophagus The mucosal lining of the esophagus may be inflamed, and this can be seen on endoscopy or on biopsy; the mucosa, however, may also be normal if esophagitis is not the cause of the pseudodiverticulosis. The condition must also be excluded from esophageal cancer, which may be done at the time of endoscopy, or which may require esophageal biopsy.

Video Endoscopic Sequence 5 of 18.

Video Clips of Esophageal intramural pseudodiverticulosis

Esophageal intramural pseudodiverticulosis (EIP) is a rare benign disease that is characterized by multiple tiny flask-shaped outpouching lesions of the esophageal wall. The etiology is unknown, but the pathologic findings include dilatation of excretory ducts of submucosal glands. The predominant symptom is dysphagia, and esophageal stricture occurs frequently. Diseases such as diabetes mellitus, esophageal candidiasis, gastroesophageal reflux disease, and chronic alcoholism are often combined. Since most EIP cases are benign, the mainstream treatment is symptom relief by endoscopic dilatation or medical treatment of accompanied diseases.

Video Endoscopic Sequence 6 of 18.

Video Clips of Esophageal intramural pseudodiverticulosis

About 200 cases of EIP have been reported world-wide1 EIP is diagnosed by characteristic findings on esophagography or esophago-gastro-duodenoscopy (EGD) and pathologic findings reveal abnormal dilatation of the submucosal glands. The predominant symptom is dysphagia often accompanied by an esophageal stricture. Here, we report a patient who suffered from chest tightness for two months, and was diagnosed as EIP by esophagography and EGD. The symptom was relieved only by taking medicine for two months, but pseudodiverticula did not vanish.

Video Endoscopic Sequence 7 of 18.

Video Clips of Esophageal intramural pseudodiverticulosis

Esophageal intramural pseudodiverticulosis is an unusual condition manifested by tiny flask-shaped outpouchings in the wall of the esophagus. The condition was diagnosed in 21 (0.15%) of 14,350 patients undergoing radiologic examinations of the esophagus at our hospitals. The pseudodiverticula were detected only by single-contrast technique in five of 18 patients (28%) who underwent both single- and double-contrast examinations. Thus, thin, low-density barium seems to enter these structures more readily than the high-density barium used for double-contrast esophagography. While most patients reported in the literature have diffuse or segmental pseudodiverticulosis associated with high esophageal strictures, the majority of our patients (11 [52%] of 21) had isolated involvement of the distal esophagus with 10 or fewer pseudodiverticula in the region of a peptic stricture. Other associated conditions included Candida esophagitis, herpes esophagitis, and squamous cell carcinoma of the esophagus. Our experience suggests that pseudodiverticulosis usually represents a sequela of reflux esophagitis, although the reason that so few patients with esophagitis develop this condition is unclear.

Video Endoscopic Sequence 8 of 18.

Video Clips of Esophageal intramural pseudodiverticulosis

Occurs in all age groups, but more commonly in the 6th and 7th decades. There is a slight male predominance.

Esophageal intramural pseudodiverticulosis, which was first described by Mendl et al. in 1960.

Video Endoscopic Sequence 9 of 18.

Video Clips of Esophageal intramural pseudodiverticulosis

Computer tomography shows localized thickening of the esophagus wall. Manometry reveals motoric dysfunction.

Video Endoscopic Sequence 10 of 18.

Fluoroscopy: barium swallow: Esophageal intramural pseudodiverticulosis

Barium swallow examination is the study of choice, as the ductal orifices are too small to be seen on endoscopy. Pseudodiverticula are best seen with a single contrast, rather than a double contrast, thin barium examination

The findings are:

Numerous tiny flask-shaped outpouchings
may be diffusely distributed or clustered.
clustering may occur next to peptic strictures
viewed in profile, often appear “floating” next to the oesophageal wall, as the channel to the lumen is impercebtible
viewed on face, may look like ulcers
intramural tracking may sometimes be seen bridging two or more pseudodiverticula

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Video Endoscopic Sequence 11 of 18.

General Considerations
Rare
Multiple flask-shaped outpouchings in the esophageal wall
Believed to be a reaction to chronic irritation, such as from
Reflux
Alcoholism
Diabetes mellitus
Candidiasis
EIP shows two peak incidences, one in the teens and the other in the 50s and 60s
Clinical Findings
About 75% have dysphagia
But it can be found incidentally
Imaging Findings
Flask-shaped outpouchings into esophageal wall from about 1-4 mm in length and 1-2 mm in width
They are distributed diffusely in 60% of patients and focally in 40% (upper 14%, middle 14%, and lower 12%)
Patients often have esophageal strictures, as well, particularly of the upper esophagus
Intramural tracking is often seen
Differential Diagnosis
Esophagitis
Carcinoma of the esophagus
Treatment
Proton-pump inhibitors
Dilatation of strictures

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Video Endoscopic Sequence 12 of 18.

Intramural Pseudodiverticulosis. images from a barium esophagram show innumerable,
small outpouchings of barium extending from the lumen into the wall.
There are also linear collections indicating intramural tracking.

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Video Endoscopic Sequence 13 of 18.

Barium esophagogram demonstrated an appearance which is pathognomonic for esophageal intramural pseudodiverticulosis and led to the definitive diagnosis of the patient and the etiology of the dysphagia.

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Video Endoscopic Sequence 14 of 18.

Esophageal intramural pseudodiverticula are dilated excretory ducts of deep mucous glands in the esophagus. Barium studies usually reveal multiple tiny, flask-shaped outpouchings in longitudinal rows parallel to the long axis of the esophagus When viewed en face, the pseudodiverticula can easily be mistaken for tiny ulcers. When viewed in profile, however, these structures often seem to be “floating” outside the esophagus, whereas true ulcers communicate directly with the lumen. Some pseudodiverticula have a diffuse distribution and are associated with high strictures, but pseudodiverticula more commonly occur in the distal esophagus in patients with peptic strictures While the pathogenesis is uncertain, it has been postulated that pseudodiverticula develop as a result of glandular dilatation from chronic inflammation. Occasionally, they may also be found in patients with alcoholism, diabetes, or Candida esophagitis.

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Video Endoscopic Sequence 15 of 18.

Esophageal intramural pseudodiverticula

Multiple motility abnormalities have been described but are not consistent. Treatment of the underlying inflammatory and or infectious condition is the mainstay of management of this unusual condition.

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Video Endoscopic Sequence 16 of 18.

Esophageal intramural pseudodiverticulosis

Radiologic appearances of EIPD with multiple small images of spicular.

Esophageal intramural pseudodiverticulosis (EIPD) is a rare benign disorder, characterized radiologically by multiple images of spicular addition of small size, localized or diffuse. Esophageal endoscopy reveals the orifice of the pseudodiverticula on only about a quarter of the lesions

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Video Endoscopic Sequence 17 of 18.

Esophagogram in a patient with intramural pseudodiverticulosis, with numerous flask-shaped outpouchings in the esophageal wall. Because these outpouchings represent the barium-filled ducts of esophageal.

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Video Endoscopic Sequence 18 of 18.

Diffuse esophageal intramural pseudodiverticulosis.

There are numerous barium-filled diverticula of the mid- and lower esphagus.

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