- Clinical science
Esophageal diverticula are abnormal pouches that arise from the wall of the esophagus. They tend to occur in middle-aged and older patients and are classified based on localization, pathophysiology, and histological findings. The most common type of esophageal diverticulum is referred to as a “Zenker's diverticulum,” which extends posteriorily in the hypopharynx directly proximal to the upper esophageal sphincter. Esophageal diverticula occur either when an underlying motility disorder exerts high intraluminal pressures on a weak esophageal wall or as a result of forces pulling on the outside of the esophagus. The clinical presentation varies with pouch size and localization, with the most common symptoms being dysphagia, regurgitation, retrosternal pain, and pulmonary symptoms secondary to aspiration. A barium swallow confirms the diagnosis, assesses the size of the diverticulum, and rules out the possiblity of cancer. Surgical treatment is rarely required and only recommended in symptomatic patients – primarily those with Zenker's diverticula.
- Rare diverticula compared to other gastrointestinal sites (prompting < 1% of all barium swallows and accounting for < 5% of all cases of dysphagia).
- Peak incidence: middle-aged and older patients
- Zenker's diverticulum is the most common type
Epidemiological data refers to the US, unless otherwise specified.
Esophageal diverticula are classified according to their localization, histology, and pathophysiology.
Although a Zenker's diverticulum is considered to be an esophageal diverticulum, it actually arises from the hypopharynx!
- True diverticula: All layers of the esophageal wall protrude.
- False diverticula: Increased intraluminal pressure causes only the mucosa and submucosa to bulge through weak points in the muscularis propria.
Pathophysiology (see “Pathophysiology” below)
- Pulsion Diverticula
- Traction Diverticula
- 3 constrictions of the esophagus
- The cervical constriction: beginning of the esophagus (upper esophageal opening) → With a diameter of about 1 cm, it is the narrowest part of the esophagus (15 cm from the upper incisor teeth).
- The thoracic constriction: point at which the esophagus crosses the aortic arch (25 cm from the upper incisor teeth)
- The abdominal constriction: point at which the esophagus passes through the diaphragm (38 cm from the upper incisor teeth; the entry of the stomach is not considered a constriction)
- Distance from the upper incisor teeth to the upper esophageal opening = 15 cm; length of the esophagus = 25 cm → 40 cm from the upper incisor teeth to the stomach
- Inadequate relaxation of the esophageal sphincter (e.g., caused by or spastic motility) and increased intraluminal pressure results in outpouching of the esophageal wall → pulsion diverticulum
- Inflammation of the mediastinum with scarring and retraction (e.g., secondary to or fungal infection) → traction diverticulum
Barium swallow (best confirmatory test) with dynamic continuous fluoroscopy
Visualization of diverticula via barium swallow or gastrografin (soluble in water)
- Best detected using lateral projection
- Shows a contrast-filled pouch protruding dorsally from the hypopharynx at the level of C5/C6.
- Allows detection of underlying motor abnormalities, possible malignancy, and diverticulum size
- A traction diverticulum presents as a pointed, triangular bulge arising from the esophageal wall; the base of the triangle is oriented towards the wall.
- Visualization of diverticula via barium swallow or gastrografin (soluble in water)
- Usually not required
- Useful for identifying underlying motor abnormalities in patients with dysphagia
- Transcutaneous ultrasound: detection of Zenker's diverticula
- There is no medical treatment for any kind of esophageal diverticula.
- Symptomatic Zenker's diverticula
- In rare cases, epiphrenic diverticula that become symptomatic
- Endoscopy; (rigid or flexible, with the former requiring general anaesthesia) with diverticulostomy and myotomy
- Open surgery
- Zenker's diverticulum: cricopharyngeal myotomy
- Epiphrenic diverticula: esophagomyotomy
- is a common complication of large Zenker's diverticula.
- In rare cases, perforation with fistula formation occurs. and
We list the most important complications. The selection is not exhaustive.