S4389 Concurrent Eosinophilic Esophagitis With Esophageal Pseudodiverticulosis: A Treatment Dilemma of Two Rare Pathologies

Introduction: Esophageal intramural pseudodiverticulosis (EIPD) is characterized by the presence of multiple small outpouchings that protrude from the esophageal lumen, resembling diverticulosis. Eosinophilic esophagitis (EoE) involves eosinophilic infiltration of the esophagus, leading to eventual dysphagia. Both are considered uncommon and their concurrent presentation is exceptionally rare. A systematic search (1960–2025) found no prior reports of EIPD with concurrent EoE and perforation. To our knowledge, we present the first reported case of this rare presentation. Case Description/Methods: A 31-year-old man presented to the emergency department with complaints of upper abdominal pain after swallowing a pill without fluids, feeling like it was stuck. Attempts to flush the pill led to multiple bouts of non-bloody emesis. A computed tomography esophagram revealed contrast in the lateral wall of the distal esophagus with pneumomediastinum. Perforation was managed with pain control, antibiotics, and NPO diet that was slowly progressed. He was discharged on 20 mg of omeprazole twice daily 4 days later. He returned 5 months later for chronic dysphagia, refractory to his proton pump inhibitors. Esophagogastroduodenoscopy revealed numerous small outpouchings, the largest measuring approximately 2 mm in diameter. Biopsies were taken from the distal, mid, and proximal esophagus. Esophageal dilation was deferred until definitive diagnosis of underlying condition was established, as well as the risk of perforation. The pathology report revealed over 40 eosinophils per high power field in each region biopsied, confirming diagnosis of EoE. Post-procedure, the patient was placed on 440 mcg of swallowed steroids twice daily in addition to his proton pump inhibitors. Discussion: This case highlights a rare concurrence of 2 uncommon esophageal conditions, EIPD and EoE, complicated by esophageal perforation. While approximately 320 cases of EIPD have been reported, a small case series noted only 2 instances of coexisting EoE with mucosal tears, and none with reported perforation. Some reports describe successful dilation for EIPD, but none in the context of recent perforation. Management is further complicated by overlapping risks: both swallowed steroids (used in EoE) and EIPD are linked to increased oral candidiasis. Dual pathology presents a therapeutic dilemma requiring individualized risk assessment and tolerance. We present a proposed treatment algorithm as a framework for management.