Oesophageal Intramural Pseudodiverticulosis

Oesophageal intramural pseudodiverticulosis is a rare condition of many small (1 to 4 mm) flask shaped outpouchings that are dilated ducts of the submucosal oesophageal glands. It is usually accompanied by strictures and presents with long standing, slowly progressive dysphagia.

It is found in about 0.1% of barium swallows and in a smaller share of endoscopies. Peak age is 50 to 70 years, with a mild male predominance.

Associations are oesophageal candidiasis, gastro oesophageal reflux, diabetes mellitus, alcohol use, motility disorders and, rarely, oesophageal carcinoma.

Pathophysiology.

Chronic inflammation of the submucosal glands obstructs their ducts, which then dilate. Periductal fibrosis causes the strictures, which lie mainly in the upper and mid oesophagus and can be long.

Intermittent or progressive dysphagia for solids, food bolus impaction, odynophagia, heartburn and regurgitation. Bleeding is rare.

Red flags.

• Complete food impaction.
• Weight loss with a new or changing stricture (exclude carcinoma).
• Chest pain or surgical emphysema after dilation (perforation).

Barium swallow shows multiple flask shaped outpouchings, often aligned along the long axis, with a smooth tapering stricture. Endoscopy shows pinpoint mucosal openings, a narrowed lumen and white candida plaques. Take biopsies of any stricture to exclude carcinoma. Endoscopic ultrasound or CT shows intramural cysts and wall thickening. Manometry is used when dysmotility is suspected.

Differential diagnosis.

• Zenker or true diverticula.
• Peptic stricture.
• Intramural haematoma or dissection.
• Eosinophilic oesophagitis.
• Oesophageal carcinoma.
• Candida oesophagitis alone.

Treat reflux and infection, dilate strictures and advise small, well chewed meals. Surgery is reserved for refractory strictures.

• Omeprazole: 20 to 40 mg orally once daily before breakfast; 8 weeks, then lowest effective dose; maximum 80 mg daily; monitor symptoms, magnesium and vitamin B12 on long courses; reduce to 20 mg daily in severe hepatic impairment.
• Fluconazole (candidiasis): 200 to 400 mg orally on day 1, then 100 to 200 mg once daily; 14 to 21 days; maximum 400 mg daily; monitor liver enzymes and QTc; halve the dose when creatinine clearance is under 50 mL/min.
• Dilation: graded bougie or balloon, raising the diameter by no more than 3 mm in one session to a target of 15 to 18 mm; repeat every 2 to 4 weeks as needed. Perforation risk is higher in long, tight strictures.

Monitoring. Symptom score and endoscopy at 3 to 6 months.

Referral and escalation. Gastroenterology for all cases; surgical review for recurrent strictures needing frequent dilation.

Special groups. In diabetes, optimise glucose control to reduce candida recurrence.