Esophageal intramural pseudodiverticulosis associated with achalasia: an unusual endoscopic appearance

Abstract

A 45-year-old woman was admitted to our hospital because of progressive dysphagia, especially in relation to solid foods, that had lasted for 3 years. A barium esophagogram revealed long intramural collections extending parallel to the long axis of the esophageal lumen with delayed emptying from the esophagus ([Fig. 1 a]). Upper endoscopy showed multiple orifices of pseudodiverticula of different sizes and the surface had a “Swiss cheese” appearance, with some of the “holes” being grouped to form a honeycomb pattern in mid esophagus ([Fig. 2] and [Video 1]). No web or stricture was seen. The biopsy specimens obtained from the edges of the pseudodiverticula revealed nonspecific esophagitis without evidence of candidal infection. Esophageal manometry using a Dent sleeve catheter demonstrated simultaneous low-amplitude peristalsis in the esophageal body and incomplete lower esophageal sphincter relaxation in response to wet swallows, suggesting a diagnosis of achalasia ([Fig. 1 b]). The patient was treated for achalasia with endoscopic esophageal injection of botulinum toxin type A. Symptoms improved and she was well for 1.5 years, but was subsequently readmitted to the hospital for recurrent dysphagia. Endoscopy again showed the same findings. A repeat injection of botulinum toxin was given and the patient’s symptoms resolved. She was discharged and advised to return if symptoms recurred.