Abstract Introduction Esophageal Intramural Pseudodiverticulosis (EIPD) is a rare condition characterized by multiple small outpouchings of the esophageal wall; it is associated with chronic inflammation or motility disorders. Although typically asymptomatic, it can present with dysphagia, esophagitis, and rarely with significant gastrointestinal bleeding. While the pathogenesis remains unknown, excessive alcohol intake, smoking, reflux, and infections can accelerate inflammatory changes that contribute to EIPD. HIV-infected patients are prone to various esophageal disorders, including opportunistic infections which worsen inflammatory changes and increase the risk of significant bleeding. We present a case of a 53-year-old male with HIV and CMV esophagitis who developed severe hematemesis due to esophageal pseudodiverticulosis, requiring urgent endoscopic interventions. Case Presentation Mr. M is a 53-year-old male with a history of HIV, recent admission for wasting syndrome (CD4 count 186, viral load 29), CMV esophagitis, and GERD who presented to the emergency department (ED) with progressively worsening fatigue and severe hematemesis (1L). In the ED, he was tachycardic, hypotensive, with hemoglobin 8.2 and continued bleeding (600 mL). He was emergently intubated, and EGD revealed esophageal pseudodiverticulosis with clotted blood and active bleeding in the distal esophagus. Initially, partial hemostasis was achieved with clips and epinephrine which prompted transfer to the MICU and he received blood products for resuscitation. In the ICU, he remained tachycardic and mildly hypotensive but stable. He continued to have hematemesis (∼300 mL), necessitating an urgent EGD, which identified active bleeding from a diverticulum. Epinephrine injection and dual clip placement successfully controlled the bleeding. He was treated with ganciclovir, TMP-SMX, and Biktarvy. He was later extubated and discharged in stable condition. Discussion Esophageal pseudodiverticulosis is an uncommon but may predispose patients to complications like strictures, infections, and severe bleeding. The mechanism of bleeding is likely due to mucosal fragility, chronic inflammation, and ulceration, particularly with CMV infection.While uncommon, complications can be severe, necessitating endoscopic or surgical intervention. The patient was treated with thereuaptic endoscopy, antiviral therapy (ganciclovir), and HIV therapy (bictegravir/emtricitabine/tenofovir alafenamide), which was crucial for achieving hemostasis, resolving CMV esophagitis and preventing recurrent bleeding. Conclusion This case highlights a rare but serious cause of esophagitis, particularly in immunocompromised patients, emphasizing its potential to cause life-threatening bleeding. Prompt recognition, endoscopic intervention, and targeted antiviral therapy are essential for successful management. This abstract is funded by: None
Akl et al. (Fri,) studied this question.