Submucosal lesion of the oesophagus: not everything is what it seems.

To cite: Carvalho AF, Rodrigues AJ, Sousa N, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2014204678 DESCRIPTION A 32 years-old woman with a history of depression, visited her doctor for heartburn and postprandial fullness with 2 months of evolution, possibly due to the consumption of non-steroid antiinflammatory drugs due to knee pain. Upper endoscopy (figure 1A) revealed a 20 mm submucosal procidentia covered with normal mucosa (most likely a submucosal tumour like) located 30 cm from the dental arch. An esophageal gastrografin swallow revealed a diverticular lesion (figure 1D). The endoscopic ultrasound revealed that it was an esophageal mesenchymal tumour—likely leiomyoma (figure 1B). CT confirmed the previous hypothesis (figure 1C). The patient underwent tumour enucleation by thoracotomy (figure 2A). A detailed anatomopathological analysis revealed an esophageal duplication cyst (CDE; figure 2B). The patient was discharged on the third postoperative day with no symptoms, tolerating soft diet. After 3 years of follow-up the patient is still asymptomatic. The first case of CDE was described by Blasius in 1711. The pathogenesis of this rare disease involves the incomplete embryological recanalisation of the upper digestive tract with subsequent coalescence of vacuoles. It is characterised by presenting pseudostratified columnar and ciliary epithelium (asterisk in figure 2B) and two layers of smooth muscle. The preferred location is in the distal thoracic oesophagus and in 90% of cases there is no communication with the oesophagus. Owing to the potential compression, haemorrhage, infection or malignancy of the cyst, the treatment of choice is surgery, regardless of the presence or absence of symptoms. The differential diagnosis includes bronchogenic cyst. This is distinguishable from the CDE histologically by the presence of cartilage.