ENDOSCOPIC INCISIONAL THERAPY FOR GIANT BRIDGED PSEUDOPOLYPOSIS OF THE ESOPHAGUS IN A PATIENT WITH UPPER GASTROINTESTINAL CROHN'S DISEASE

Background: Pseudopolyposis is a rare phenotype of esophageal Crohn's disease (eCD) that develops from repeated cycles of inflammation and healing. “Bridged” types have elongated, filiform morphologies that connect opposing walls of the esophageal lumen. Endoscopic incisional therapy (EIT) applies radial incision and cutting of tissue with an electrocautery-enhanced needle-knife to restore adequate luminal patency. While this technique has established technical feasibility and efficacy for benign esophageal strictures refractory to dilation, to our knowledge, it has yet to be demonstrated in eCD with bridged pseudopolyposis.
Case Presentation: A 38-year-old male with ileocolonic and stricturing eCD was referred for a sixteen-year history of solid-food dysphagia and weight loss. He was strictly adherent to a pureed diet. Medical management and serial bougie dilation were previously unsuccessful. We thus performed esophagogastroduodenoscopy (EGD) for evaluation of EIT.
Endoscopic Methods: A tight proximal stricture was noted 20 cm from the incisors. A balloon dilation catheter was used to expand the stricture up to 13.5 mm. Distally, we encountered many giant bridged pseudopolyps which formed a complex web-like tract. The gastroscope was carefully negotiated through the entire segment. We performed EIT with an insulated-tip (IT)-type endoscopic submucosal dissection (ESD) knife. Beginning proximally, we incised each pseudopolyp bridge in a radial fashion towards the center of the esophageal lumen. After releasing each bridge, the remnant filiform-type tissue was resected with a 15 mm snare. Post-procedure, the patient tolerated an advanced, solid-food diet. Follow-up EGD in one month again revealed the proximal stricture which was traversable only with an ultra-slim gastroscope. Multiple false-lumens with retained debris were seen just distal to the stricture, potentially representing long-segment bridged pseudopolyps. The prior EIT segment appeared patent and well-healed. To provide further clinical improvement and prevent debris accumulation, repeat EIT for false-lumen takedown was performed. A needle-knife was fabricated to fit through a 2.2 mm working channel of the ultra-slim gastroscope. This was created by cutting the distal tip of a 5.5 French miniature ERCP sphincterotome. After placing a guidewire through each tract, the false-lumens were sequentially cut and opened. Post-procedure, there was no evidence of contrast extravasation. The passage of a regular gastroscope confirmed luminal patency and no evidence of mucosal injury.
Conclusions: EIT appears to be safe, technically feasible, and effective in the management of symptomatic eCD with bridged pseudopolyposis. Long-term follow-up is required to assess recurrence and treatment durability. Prospective study is warranted for procedural standardization and optimal instrument selection.