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esophageal diverticulum

Esophageal diverticulum

Esophageal diverticulum is a pouch that protrudes outward in a weak portion of the esophageal lining and is usually asymptomatic 1. This pocket-like structure can appear anywhere in the esophageal lining between the throat and stomach.

Esophageal diverticulum can affect people of all ages, although most cases occur in middle-aged and elderly individuals.

Overall, esophageal diverticulum is rare, showing up in less than 1 percent of upper gastrointestinal X-rays and occurring in less than 5 percent of patients who complain of difficulty in swallowing (dysphagia) 2. Esophageal diverticula are found in approximately 1% to 3% of those presenting with dysphagia. It can occur in all ages but are typically diagnosed in the elderly. Esophageal diverticulum is usually found more in men than in women.

Typically, esophageal diverticulum is a nuisance that enlarge slowly over many years, gradually producing increasing symptoms, such as difficulty in swallowing (dysphagia), regurgitation and aspiration pneumonia, caused by breathing in regurgitated diverticulum content. Patients typically present when they have symptoms of regurgitation or dysphagia.

When symptoms of esophageal diverticulum worsen, a person may be unable to swallow due to an obstruction near the diverticulum; rarely, the esophagus may rupture. An obstruction or rupture caused by an esophageal diverticulum is dangerous, and both complications require immediate attention.

Regurgitation caused by a esophageal diverticulum often occurs at night when lying down, which can lead to choking, aspiration pneumonia (a lung infection caused by pulmonary aspiration, the entry of secretions or foreign material into the trachea and lungs), and lung abscesses.

Although rare, squamous cell carcinoma can develop in 0.5 percent of those with esophageal diverticulum. This is thought to be caused by chronic irritation of the diverticulum by prolonged food retention. It is important to note that the fear of cancer is not a reason to surgically treat esophageal diverticulum.

If patients are asymptomatic, then the esophageal diverticulum are left intact 3. This is usually the case in mid-esophageal and epiphrenic diverticulum 4. However, for symptomatic patients, there are surgical and endoscopic therapeutic options. This is more often seen in the pharyngeal diverticulum. Therapeutic options include diverticulectomy, diverticulopexy, and diverticulumr inversion, with or without myotomy, and myotomy alone 5. Surgical options include open or laparoscopic approach. Most often, patients undergo minimally invasive myotomy and removal of the pouch endoscopically with either a soft or rigid endoscope 6. If patients are not surgical candidates, then management with diet changes such as eating bland food and drinking water after every bite to help flush any food out of the diverticulum is recommended.

Figure 1. Esophageal diverticulum

Esophageal diverticulum types

There are different ways to categorize esophageal diverticulum. Esophageal diverticulum can be divided into true and false diverticulum. The esophagus is composed of 4 layers; from the lumen going outward, they are the mucosa, submucosa, muscularis, and adventitia. True diverticulum is an outpouching that includes all 4 layers of the esophageal wallof all esophageal 3. With false diverticulum, only the mucosa and submucosa layers will be seen. Squamous cell carcinoma can rarely be found in conjunction with esophageal diverticulum.

An esophageal diverticulum can also be characterized by how it is formed: pulsion or traction 7. Pulsion diverticulum are created when there is increased intraluminal pressure causing herniation of the esophageal wall in an area of weakness and usually occur in the setting of dysmotility of the esophagus 8. Traction diverticulum occur when there is an external force on the esophageal wall such as mediastinal inflammation that adheres and pulls on the esophageal wall creating a defect or diverticulum.

Esophageal diverticulum is classified by their location within the esophagus:

  • Zenker’s diverticulum (pharyngoesophageal or pharyngeal diverticulum) is the most common epiphrenic diverticulum type. Zenker’s diverticulum is usually located in the back of the throat, just above the esophagus
  • Midthoracic diverticulum (mid-esophageal diverticulum), in the mid-chest
  • Epiphrenic diverticulum, above the diaphragm

An esophageal diverticulum can also be categorized based on location as pharyngeal (Zenker) diverticulum, mid-esophageal diverticulum, and epiphrenic diverticulum. Pharyngeal diverticulum are considered false diverticulum 2. They usually occur in the hypopharynx where there is a weakness in the area known as Killian’s triangle 9. Killian’s triangle is an area bound by the cricopharyngeus muscles and inferior pharyngeal constrictor muscles. These are usually formed by pulsion. A mid-esophageal diverticulum is usually true diverticulum and normally caused by traction from mediastinal inflammation. Epiphrenic diverticulum are usually false diverticulum located in the distal 10 cm of the esophagus. Similar to pharyngeal diverticulum, they are also usually caused by pulsion from motility disorders that cause an increase in lower esophageal sphincter pressure such as achalasia.

What causes esophageal diverticulum?

While the first case of an esophageal diverticulum was reported nearly 250 years ago, little is still known about this condition. It is believed that the internal pressure produced by the esophagus to move food into the stomach can herniate the esophageal lining through a weakened wall, creating a pouch or a diverticulum 7. There is usually distal end obstruction.

Esophageal diverticulum are more common in people who have motility disorders of the esophagus, such as achalasia, that cause difficulty in swallowing, regurgitation of food, and, in some people, a spasm-type pain 1.

Esophageal diverticulum symptoms

The symptoms of esophageal diverticulum include:

  • Dysphagia (difficulty swallowing, characterized by a feeling of food caught in the throat)
  • Pulmonary aspiration (the entry of secretions or foreign material into the trachea and lungs)
  • Aspiration pneumonia (a lung infection caused by pulmonary aspiration)
  • Regurgitation of swallowed food and saliva
  • Pain when swallowing
  • Cough
  • Neck pain
  • Weight loss
  • Bad breath (halitosis)

Some people may experience a gurgling sound as air passes through the esophageal diverticulum. This is known as Boyce’s sign.

Esophageal diverticulum complications

Esophageal diverticulum complications are rare but include esophageal obstruction, perforation, and squamous cell carcinoma 10.

Esophageal diverticulum diagnosis

The tests most commonly used to diagnose and evaluate esophageal diverticulum include:

  • Barium swallow (barium esophagram): The patient swallows a barium preparation (liquid or other form) and its movement through the esophagus is evaluated using X-ray technology.
  • Esophagogastroduodenoscopy: A flexible, narrow tube called an endoscope is passed through the gastrointestinal tract and projects images of the inside onto a screen.
  • Esophageal manometry: This test measures the timing and strength of esophagus contractions and muscular valve relaxations.
  • 24-hour pHmetry: A test to check for the presence of gastroesophageal reflux disease (GERD).

Most patients are diagnosed by barium esophagram 3. This study helps give information regarding location and size besides the diagnosis. Esophagogastroduodenoscopy can be done to confirm the diagnosis and is sometimes the initial diagnostic test. They can also be found incidentally on video swallow studies.

Esophageal diverticulum treatment

Cases of esophageal diverticulum that cause minor symptoms can be treated through lifestyle changes, such as eating a bland diet, chewing food thoroughly, and drinking plenty of water after meals.

If symptoms become severe, several types of surgery are available to remove the esophageal diverticulum, repair the defects and relieve a patient’s symptoms and improve their quality of life.

Treatment of esophageal diverticulum require:

  • An examination of the diverticulum;
  • Repair of the weakened wall; and
  • Relief of obstruction

Esophageal diverticulum surgery

The type of surgical treatment recommended depends on the size and location of esophageal diverticulum and include:

  • Cricopharyngeal myotomy: Used in the removal of small diverticulum, this surgical treatment can be completed using an open or trans oral approach.
  • Diverticulopexy with cricopharyngeal myotomy: Used to remove larger diverticulum, this procedure involves turning the diverticulumr sac upside down and suspending it by suturing it to the esophageal wall.
  • Diverticulectomy and cricopharyngeal myotomy: Diverticulectomy for the treatment of Zenker’s diverticulum has been performed for almost a century. The procedure involves complete excision of the diverticular sac.Recently surgeons have improved the outcome of this procedure by adding the Heller myotomy laparoscopic approach to ensure the movement of food through the lower esophageal sphincter.
  • Endoscopic diverticulotomy (Dohlman procedure): This procedure divides the septum between the cervical esophagus and the diverticulumr pouch. By dividing the septum, food can freely drain from the pouch to the esophagus. Surgeons complete this division by using a Zenker’s diverticuloscope and a minimally invasive stapling technique to treat Zenker’s diverticulum.

Laparoscopic approaches, such as endoscopic diverticulotomy, offer patients many benefits, including:

  • Limited number of small scars instead of one large abdominal scar
  • Shorter hospital stay
  • Reduced postoperative pain
  • Shorter recovery time
  • Quicker return to daily activities, including a regular diet

What are the risks of minimally invasive surgery to treat esophageal diverticulum?

The possible complications of minimally invasive surgery include:

  • Damage to the lung, spleen, stomach, esophagus or liver
  • Postoperative infection or bleeding
  • Pneumonia
  • Deep vein thrombosis (DVT)

Post-operative complications include bleeding, hematoma, infection, esophageal leaking at the repair site, fistula formation, mediastinal infection, esophageal perforation, esophageal stenosis, recurrent laryngeal nerve injury, and pneumomediastinum 10. The rate of these complications will, of course, depend on the surgical or endoscopic approach and skill of the surgeon.

Your health care team will discuss the possible risks and benefits of each procedure with you.

Esophageal diverticulum prognosis

Prognosis of esophageal diverticulum patients is dependent on their age and comorbidities as this will determine their surgical candidacy 10. Risks and benefits need to be weighed. Most patients will have good results as far as immediate resolution of symptoms with surgical treatment with varied recurrence rates. However, surgical complications can be serious and need to be considered when deciding on whether to pursue surgical treatment and which surgical approach to pursue.

References
  1. Yam J, Ahmad SA. Esophageal Diverticula. [Updated 2019 Feb 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532858
  2. Hussain T, Maurer JT, Lang S, Stuck BA. [Pathophysiology, diagnosis and treatment of Zenker’s diverticulum]. HNO. 2017 Feb;65(2):167-176.
  3. Little RE, Bock JM. Pharyngoesophageal diverticuli: diagnosis, incidence and management. Curr Opin Otolaryngol Head Neck Surg. 2016 Dec;24(6):500-504.
  4. Fékéte F, Vonns C. Surgical management of esophageal thoracic diverticula. Hepatogastroenterology. 1992 Apr;39(2):97-9.
  5. Thomas ML, Anthony AA, Fosh BG, Finch JG, Maddern GJ. Oesophageal diverticula. Br J Surg. 2001 May;88(5):629-42.
  6. Khullar OV, Shroff SR, Sakaria SS, Force SD. Midesophageal Pulsion Diverticulum Resulting From Hypercontractile (Jackhammer) Esophagus. Ann. Thorac. Surg. 2017 Feb;103(2):e127-e129
  7. Wang ZM, Zhang SC, Teng X. Esophageal diverticulum serves as a unique cause of bronchoesophageal fistula in children: A case report. Medicine (Baltimore). 2017 Dec;96(51):e9492
  8. Sonbare DJ. Pulsion Diverticulum of the Oesophagus: More than just an Out Pouch. Indian J Surg. 2015 Feb;77(1):44-8.
  9. Le Mouel JP, Fumery M. Zenker’s Diverticulum. N. Engl. J. Med. 2017 Nov 30;377(22):e31
  10. Yuan Y, Zhao YF, Hu Y, Chen LQ. Surgical treatment of Zenker’s diverticulum. Dig Surg. 2013;30(3):207-18.
Health Jade Team

The author Health Jade Team

Health Jade