A 68-year-old Saudi man (non-smoker, non-diabetic, with an insignificant past medical history) presented with complaints of dysphagia of 2 weeks’ duration and haematemesis of 1 day duration. The patient’s examination was unremarkable and investigations revealed a haemoglobin of 14 g % with normal serum chemistry and cell counts. The patient was treated with pantoprazole 40 mg twice daily. An osophagogastroduodenoscopy was done which revealed diffuse oesophageal candidiasis (fig 1). In view of this the patient was screened for HIV which was negative. The patient received oral fluconazole 100 mg daily and there was symptomatic improvement. Two weeks later oesophagogastroscopy was repeated which revealed healed oesophagitis with some areas of erythema and a large epiphrenic diverticulum containing a mobile egg shaped friable mass (fig 2). Histology revealed Candida albicans. Thus an oesophageal fungal bezoar was diagnosed with severe candida oesophagitis. The patient underwent a computed tomography (CT) scan of the chest and abdomen and a barium swallow (fig 3). This confirmed the diverticulum and the patient underwent open thoracotomy and resection of the diverticulum. The patient is currently doing well. We report this unusual association and presentation of oesophageal epiphrenic diverticulum as extensive oesophageal candidiasis.

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Figure 1

Oesophageal candidiasis as presentation of epiphrenic oesophageal fungal bezoar.

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Figure 2

Egg shaped fungal bezoar in epiphrenic diverticulum.

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Figure 3

Barium swallow showing epiphrenic diverticulum.

Oesophageal diverticula are classified by location: phreno-oesophageal (Zenker’s diverticulum, 70%), thoracic and mediastinal (10%), and epiphrenic (20%). Almost all oesophageal diverticula are acquired pulsion diverticula.1 Epiphrenic diverticulum is common and contents like food material have been found.2 Oesophageal bezoars in a normal oesophagus have been reported in a case of myasthenia gravis with casein and sucralfate as the contents.3 Endoscopic removal of oesophageal bezoars is reported but our case is unique in presentation as well as its friable content of the fungus C albicans.

A laparoscopic approach is the surgical treatment of choice. A long myotomy and an antireflux procedure should be added to avoid oesophageal leakage at the line of repair and gastro-oesophageal reflux.