Teaching Case

Episodic dysphagia

Episodic dysphagia and retrosternal burning occurred since infancy. Esophagitis and luminal stricture (extended about 10cm) were observed at endoscopy in the lower third of the esophagus. Double contrast esophagograms showed a minimal hold-up to fluid barium and many intramural pseudodiverticula were visualized in the narrowed region. No evidence of abnormality of esophageal motility that could explain the patogenesis of pseudodiverticula was observed.

Esophageal intramural pseudodiverticulosis is a rare and benign affection that can also develop in early age. Many etiological speculations have been suggested but the true cause of this affection remains still unknown. Usually pseudodiverticula develop at the level of strictures or below; this aspect rules out mechanical pressure as etiological factor of pseudodiverticulosis. The inflammatory infiltrate of chronic esophagitis could lead to glandular duct obstruction, and pseudodiverticuli seem to be induced by glandular dilatation for duct obstruction. On the other hand, it is also possible that the localized inflammatory changes occur secondary to an abnormal development of the mucous gland. Inflammation and ulcerations are oftenly associated to pseudodiverticula but their morphology is different; pseudodiverticula reminds the form of a glandular duct and ulcers are commonly deeper. Pseudodiverticula presents with a thin neck (<1mm) and frequently remains unvisualized, differently from ulcerations. Moreover ulcers disappear or decrease after medical theraphy differently from pseudodiverticula.