Post written by Sarang Gupta, MD, and Jeffrey Mosko, MD, from St. Michael’s Hospital and the University of Toronto, Toronto, Canada.

A 38-year-old man with stricturing esophageal Crohn’s disease (eCD) was referred for evaluation of progressive solid-food dysphagia despite medical therapy and prior dilation attempts. After balloon dilation of a proximal esophageal stricture, examination of the distal esophagus revealed a complex web-like tract comprised of numerous giant bridged pseudopolyps explaining the patient’s refractory symptoms (Fig. 1A).

Beginning proximally, we performed endoscopic incisional therapy (EIT) with an insulated tip–type endoscopic submucosal dissection knife (Fig. 1B). Each pseudopolyp bridge was cut in a radial fashion toward the center of the lumen followed by snare resection of the remnant filiform-type tissue.

Follow-up EGD in 1 month again revealed the tight proximal stricture. Using an ultraslim gastroscope, we were able to identify longer bridged pseudopolyps that formed false lumens with retained debris just distal to the stricture. We planned repeat EIT for false-lumen takedown. However, as the 2.2-mm working channel of the ultraslim gastroscope limited us, we first fabricated a miniature needle-knife by cutting the distal tip of a 5.1F ERCP sphincterotome.

Sequentially, a guidewire was inserted into each of the false lumens and used as a scaffold to facilitate our goal of cutting the bridges craniocaudally toward the true lumen to avoid esophageal perforation. Postprocedural evaluation confirmed luminal patency without deep mucosal injury or contrast extravasation.

At 1-year follow-up, the patient was able to maintain a solid-food diet. EGD concurrently revealed a patent and well-healed esophagus with no recurrence of the obstructive bridged pseudopolyps.

We demonstrated application of EIT, a known advanced endoscopic technique, in the novel (and rare) setting of complex eCD with an uncommon manifestation of bridged pseudopolyposis. In addition, this case allowed us to highlight that EIT can be safe, technically feasible, and effective in the management of symptomatic eCD refractory to standard treatment.

Early multidisciplinary discussion among inflammatory bowel disease specialists and advanced endoscopists is encouraged for challenging and/or atypical cases to facilitate prompt treatment of eCD. Although we established clinical success at 1-year follow-up, long-term evaluation is still required to assess pseudopolyp disease recurrence and treatment durability.

Diagnosis and management of distal esophageal bridged pseudopolyposis using a regular gastroscope after proximal stricture balloon dilation. A, Luminal obstruction secondary to bridged pseudopolyps in the distal esophagus. B, EIT of a giant bridged pseudopolyp using an insulated tip–type ESD knife. C, Improved luminal patency was achieved after consecutive EIT and snare resection of the distal esophageal bridged pseudopolyps. ESD, Endoscopic submucosal dissection; EIT, endoscopic incisional therapy.

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