Diffuse intramural esophageal diverticulosis is a rare disease that is characterized by multiple tiny flask-shaped outpouching lesions of the esophageal wall. These outpouchings represent the ducts of submucosal glands of the esophagus, and for this reason, the disorder is also called esophageal intramural pseudodiverticulosis (EIP). It was first described by Mendl et al. in1960. Usually, cases present with dysphagia and food impaction in association with a proximal esophageal stricture. The diagnosis is usually made radiologically, endoscopically, and pathologically.
While the exact etiology of the condition is unclear and needs to be further clarified, multiple studies have shown that alcohol consumption and tobacco smoking are the leading associated risk factors. Furthermore, the first possible association with esophageal moniliasis was mentioned by Troupin, who suggested the causal relationship between the two. Other correlations that have been referred to in the literature are gastroesophageal reflux disease, whether with or without hiatal hernia, diabetes mellitus, corrosive ingestion, Plummer-Vinson syndrome, and esophageal carcinomas. Several reports have suggested an association with motility disorders as a predisposing factor for the condition.
Diffuse intramural esophageal diverticulosis is a rare benign disease. It is suggested that there are only about 200 reports published all around the world. Moreover, in one study which looked at 14,350 barium swallow esophagrams, this clinical entity was identified only in 21 of the patients that underwent the diagnostic procedure (that is about 0.15%). The disease can affect any age. In a series of 97 cases reported, the age range was between 8 months and 86 years with a mean age of 53.5 years. In that same series, it was found that 58% were males and 42% were females. On the other hand, it was shown by other studies that this disease follows a bimodal pattern of age distribution affecting teenagers and patients in their 50s and 60s.
The exact pathogenesis of diffuse intramural esophageal diverticulosis is unclear and controversial. These diverticula or pseudodiverticula are composed of pathologically dilated submucosal glands with surrounding inflammatory cells, so it is postulated that inflammation plays an essential role in their pathogenesis. Furthermore, given the association of esophageal intramural diverticulosis (EIP) with esophagitis and the fact that esophagitis is correlated with hypertensive lower esophageal sphincter, therefore, Bender et al. assumed that diverticular formation might have resulted from motility changes secondary to the inflammation in esophagitis. Conversely, Creely and Trail performed manometric studies in esophageal intramural diverticulosis and found no signs of spasm or hyperperistalsis in the esophagus. Moreover, their cultured esophageal endoscopic washings came back negative for Candidiasis, which argues against EIP being caused by that fungus. As a result of the presence of Candida in some cases and its absence others, it is suggested that esophageal candidiasis could be the cause or the result of EIP. Likewise, esophageal strictures could be resulting in EIP, considering that they were present in many of the reported cases. Contrarily, other EIP reports showed a distribution of the diverticula distal to the stricture or complete absence of strictures, so one may argue that strictures are just the result of EIP rather than being the cause.
Patients with diffuse intramural esophageal diverticulosis usually present with chronic dysphagia that is either constant, intermittent, or progressive and is usually for solids or less likely manifest with food impaction, which usually resolves spontaneously. Nonetheless, some patients are asymptomatic, and the condition is diagnosed accidentally during workup for other issues. The mean time from the development of difficulty swallowing to diagnosis is usually 60.5 months (range two days to 26 years), as was reported in one of the studies. Other manifestations include chest pain, chest tightness, odynophagia, and upper gastrointestinal bleed.
Radiological examination using a single or double-contrast technique is more sensitive than the endoscopic exam in the diagnosis of esophageal intramural pseudodiverticulosis (EIP) because diverticular orifices can be tiny and hence difficult to visualize with endoscopy. Radiologically, they are demonstrated by flask-shaped outpouchings that are few millimeters in size and are distributed either diffusely or segmentally. Endoscopically, the diverticula may be missed given tiny orifices; however, when found, they look like small yellow-white mucosal elevations with or without fluid expressed from them. Furthermore, endoscopy is important in diagnosing or excluding coexisting conditions like strictures, Barret esophagus, esophagitis, or cancer by direct visualization and/or biopsy. On computed tomography, the esophageal wall might appear hypertrophied with some irregular luminal narrowing. Other studies used manometry for the evaluation of the condition, and they found out a range of motility issues, including local or diffuse aperistalsis, decreased amplitude with normal peristalsis, decreased amplitude with aperistalsis, high amplitude contractions, diffuse esophageal spasms, or normal amplitude with synchronous tertiary contractions.
The treatment is directed toward the accompanying medical conditions and symptoms relief, with approximately 10% of cases not necessitating any interventions. Therefore, antireflux medications for patients with coexisting gastroesophageal reflux disease or esophagitis, and treating associated esophageal Candidiasis, when present, have been shown to improve symptoms. Moreover, mechanical dilatation of the accompanying esophageal strictures has shown to result in considerable clinical response and, in some cases, resulted in a reduction in the number of or even complete disappearance of the diverticula.
Other conditions that fall in the differential diagnoses of diffuse intramural esophageal diverticulosis are other causes of dysphagia. Furthermore, many of these conditions usually coexist with EIP and said to be risk factors for it. Those include gastroesophageal reflux disease, esophagitis, esophageal stricture due to other causes, esophageal carcinoma, or motility disorders.
The diverticula themselves may have no clinical importance, and whether or not they disappear with treatment has no relationship to the clinical outcome of the patients. Nonetheless, they can be an indicator of underlying or co-existing conditions as most of the complications are usually not the direct result of the diverticulosis but may be resulted from similar underlying pathophysiology, so the overall nature of the condition is benign, but there is a reported correlation with esophageal cancer.
The most common complication that a patient with diffuse intramural esophageal diverticulosis suffers from is the development of an esophageal stricture that can be observed in up to 76% to 90% of patients and is mostly found in the upper esophagus, followed by the lower esophagus then the middle esophagus. There is an increased prevalence of EIP in patients diagnosed with esophageal cancer; however, the association is not clear and requires further confirmation. In other words, EIP could be the cause of or the result of esophageal cancer, or could both share the same etiologic and pathogenic factors. Another reported rare fatal complication is fistula formation with the anterior mediastinum.
Although diffuse intramural esophageal diverticulosis is a rare condition, physicians should keep it in the back of their minds when evaluating a patient with dysphagia. Patients, on the other side, should be educated that dysphagia is never normal, and they should seek help as soon as possible.
Diffuse intramural esophageal diverticulosis is one of the causes of gastrointestinal symptoms, especially dysphagia. Health care providers need to consider it whenever dealing with a patient with dysphagia. Since dysphagia is the usual presentation for our subject of interest and since all health care providers must diagnose and intervene when a patient presents with dysphagia, we will describe below some recommendations to deal with patients who present with dysphagia.
Dysphagia is defined as difficulty in swallowing. It can be divided into oropharyngeal versus esophageal. The first indicates difficulty initiating swallowing and is mostly due to motility disorders, while the latter denotes the inability of transporting food down the esophagus with a feeling of food stuck in the esophagus. Furthermore, esophageal dysphagia can be attributed to motility disorders like achalasia and esophageal spasms, and other causes can be due to structural issues like esophageal cancer, esophagitis, esophageal webs and rings, diverticulosis, or strictures.
Below, are recommendations taken from "Clinical Practice Guidelines for the Assessment of Uninvestigated Esophageal Dysphagia" published in Journal of the Canadian Association of Gastroenterology, 2018 :
1) In patients presenting with dysphagia, it is recommended to use history and physical exam to identify oropharyngeal causes.
2) In patients with esophageal dysphagia, it is recommended to use history to differentiate structural and motility disorders of the esophagus.
3) In patients presenting with esophageal dysphagia, it is recommended to use history and physical exam, including alarm features like vomiting, gastrointestinal bleeding, unexplained weight loss, abdominal mass, or anemia, to ensure timely management especially need for urgent investigations.
4) In patients with esophageal dysphagia, endoscopy is recommended over barium esophagram to improve the diagnosis of structural esophageal disease. On the other hand, barium esophagram is to be chosen over endoscopy whenever there is limited local access to endoscopy with efforts for timely referral for endoscopy at other facilities.
5) For patients who are under the age of 50 years who present with esophageal dysphagia and reflux with no alarm features, it is recommended to investigate after the patient failed a trial of oral proton pump inhibitors (PPI), taken twice daily for 4 weeks.
6) Esophageal manometry is used in evaluating persistent dysphagia after excluding structural causes as it is considered the gold standard for diagnosing esophageal motility disorders.
|||Eliakim R,Libson E,Rachmilewitz D, Diffuse intramural esophageal pseudodiverticulosis. Journal of the National Medical Association. 1989 Jan; [PubMed PMID: 2498526]|
|||Castillo S,Aburashed A,Kimmelman J,Alexander LC, Diffuse intramural esophageal pseudodiverticulosis. New cases and review. Gastroenterology. 1977 Mar; [PubMed PMID: 401752]|
|||Halm U,Lamberts R,Knigge I,Mössner J,Zachäus M, Esophageal intramural pseudodiverticulosis: endoscopic diagnosis and therapy. Diseases of the esophagus : official journal of the International Society for Diseases of the Esophagus. 2014 Apr; [PubMed PMID: 23834490]|
|||Troupin RH, Intramural esophageal diverticulosis and moniliasis. A possible association. The American journal of roentgenology, radium therapy, and nuclear medicine. 1968 Nov; [PubMed PMID: 4972118]|
|||Sabanathan S,Salama FD,Morgan WE, Oesophageal intramural pseudodiverticulosis. Thorax. 1985 Nov; [PubMed PMID: 3934782]|
|||Chon YE,Hwang S,Jung KS,Lee HJ,Lee SG,Shin SK,Lee YC, A case of esophageal intramural pseudodiverticulosis. Gut and liver. 2011 Mar; [PubMed PMID: 21461080]|
|||Hahne M,Schilling D,Arnold JC,Riemann JF, Esophageal intramural pseudodiverticulosis: review of symptoms including upper gastrointestinal bleeding. Journal of clinical gastroenterology. 2001 Nov-Dec; [PubMed PMID: 11606853]|
|||Bender MD,Haddad JK, Disappearance of multiple esophageal diverticula following treatment of esophagitis: serial endoscopic, manometric, and radiologic observations. Gastrointestinal endoscopy. 1973 Aug; [PubMed PMID: 4199814]|
|||Wightman AJ,Wright EA, Intramural oesophageal diverticulosis: a correlation of radiological and pathological findings. The British journal of radiology. 1974 Aug; [PubMed PMID: 4213630]|
|||Umlas J,Sakhuja R, The pathology of esophageal intramural pseudodiverticulosis. American journal of clinical pathology. 1976 Mar; [PubMed PMID: 816192]|
|||Herter B,Dittler HJ,Wuttge-Hannig A,Siewert JR, Intramural pseudodiverticulosis of the esophagus: a case series. Endoscopy. 1997 Feb; [PubMed PMID: 9101148]|
|||Plavsic BM,Chen MY,Gelfand DW,Drnovsek VH,Williams JP 3rd,Kogutt MS,Terry JA,Plenkovich D, Intramural pseudodiverticulosis of the esophagus detected on barium esophagograms: increased prevalence in patients with esophageal carcinoma. AJR. American journal of roentgenology. 1995 Dec; [PubMed PMID: 7484570]|
|||Levine MS,Moolten DN,Herlinger H,Laufer I, Esophageal intramural pseudodiverticulosis: a reevaluation. AJR. American journal of roentgenology. 1986 Dec; [PubMed PMID: 3096096]|
|||Brühlmann WF,Zollikofer CL,Maranta E,Hefti ML,Bivetti J,Giger M,Wellauer J,Blum AL, Intramural pseudodiverticulosis of the esophagus: report of seven cases and literature review. Gastrointestinal radiology. 1981; [PubMed PMID: 6796452]|
|||Cho SR,Sanders MM,Turner MA,Liu CI,Kipreos BE, Esophageal intramural pseudodiverticulosis. Gastrointestinal radiology. 1981 Jan 15; [PubMed PMID: 6790328]|
|||Abdel Jalil AA,Katzka DA,Castell DO, Approach to the patient with dysphagia. The American journal of medicine. 2015 Oct; [PubMed PMID: 26007674]|
|||Liu LWC,Andrews CN,Armstrong D,Diamant N,Jaffer N,Lazarescu A,Li M,Martino R,Paterson W,Leontiadis GI,Tse F, Clinical Practice Guidelines for the Assessment of Uninvestigated Esophageal Dysphagia. Journal of the Canadian Association of Gastroenterology. 2018 Apr; [PubMed PMID: 31294391]|