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C A S E

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History: A 37-year-old man has recurrent episodes of dysphagia.


1. Which of the following should be included in the
differential diagnosis of the imaging finding shown in
figure A? (Choose all that apply.)
A. Herpetic esophagitis
B. Candida esophagitis
C. Zenkers diverticula
D. Esophageal diverticula
E. Intramural pseudodiverticulosis
2. What structures are visible, filled by the barium?
A. Chronic ulcerations
B. Fibrosed traction diverticula
C. Scarred pulsion diverticula
D. Dilated excretory ducts of the esophageal mucous
glands
3. What is the most common other esophageal abnormality
seen with this condition?
A. Ulcerative esophagitis
B. Benign stricture
C. Malignant stricture
D. True diverticula
4. What pathogen has been associated with this condition?
A. Actinomyces organisms
B. Mixed oral flora
C. Candida organisms
D. Helicobacter pylori

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A N S W E R S
C A S E

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Esophageal Intramural Pseudodiverticulosis


1. A, D, and E
2. D
3. B
4. C
References
Levine MS: Other esophagitides. In Gore RM, Levine MS (eds): Textbook
of Gastrointestinal Radiology, 2nd ed. Philadelphia: WB Saunders, 2000,
pp 381-384.

Cross-Reference
Gastrointestinal Imaging: THE REQUISITES, 3rd ed, p 30.

Comment
Intramural pseudodiverticulosis of the esophagus is a rare
condition. Anatomically it represents barium filling the sparse
adenomatous excretory ducts of the mucous glands of the
esophagus. These mucous glands are normal anatomic structures of the esophagus but typically are not visible on radiologic studies. However, sometimes (thought to relate to chronic
inflammation) these ducts become dilated, allowing barium to
track into the ducts and glands.
Some type of inflammation must be present for these
pathologic changes to occur, and the large majority of these
patients have evidence of esophageal inflammation. A large
proportion of patients with intramural pseudodiverticulosis
also have strictures. The strictures are typically benign, but
intramural pseudodiverticulosis has been reported in association with malignant strictures. Candida organisms have been
found in patients with this condition, but the exact causal relationship is uncertain. More than likely, this finding represents
a secondary infection of the glands and not a predisposing
condition. Rarely this condition is found in patients with an
otherwise normal esophagus. However, the very presence of
intramural pseudodiverticulosis is abnormal.
Radiologically the intramural pseudodiverticulosis appears as
small outpouchings, often with a flask shape. These outpouchings are most commonly mistaken for ulcers by those who are
unfamiliar with the condition. Intramural pseudodiverticulosis
may be either segmental or diffuse. Even intramural tracking
and deep penetration may be evident. On CT, the condition
produces changes of esophageal wall thickening and irregularity of the lumen, mimicking esophageal carcinoma. Because it
is primarily a radiologic oddity, the conditions clinical course
depends on treatment of the underlying condition.
Often, treatment of the stricture or inflammation results in
a decrease or even disappearance of the pseudodiverticulosis.
Slightly increased risks of adenocarcinoma of the esophagus
have been associated with this condition.
Notes

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