• Clinical science

Esophageal diverticula (Esophageal pouches)

Abstract

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.

Epidemiology

  • 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

References:[1][2][3]

Epidemiological data refers to the US, unless otherwise specified.

Classification

Esophageal diverticula are classified according to their localization, histology, and pathophysiology.

  • Localization
    • Upper esophageal diverticulum
    • Middle esophageal diverticulum: diverticulum at the tracheal bifurcation
    • Lower esophageal diverticulum: epiphrenic diverticulum

Although a Zenker's diverticulum is considered to be an esophageal diverticulum, it actually arises from the hypopharynx!

  • Histology
    • 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

References:[1][2][4][3]

Pathophysiology

Anatomy

  • 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 cm40 cm from the upper incisor teeth to the stomach

Pathogenesis

References:[1][2][5][3]

Clinical features

Clinical presentation depends on diverticulum size and localization

  • Dysphagia (most common)
  • Regurgitation of undigested food
  • Aspiration
  • Coughing after food intake
  • Retrosternal pressure sensation and pain
  • Halitosis
  • Weight loss
  • Neck mass

References:[1][2][6][3]

Diagnostics

  • 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.
  • Endoscopy
    • Indication: to rule out malignancy in the pouch and exclude other causes of the patient's symptoms (e.g., tumor and reflux esophagitis)
    • Less sensitive, since diverticula with small openings may be missed
    • Risk of diverticulum perforation, since the course of the esophagus is often irregular
  • Esophageal manometry
    • Usually not required
    • Useful for identifying underlying motor abnormalities in patients with dysphagia
  • Transcutaneous ultrasound: detection of Zenker's diverticula

References:[1][2][4][7][8]

Treatment

  • There is no medical treatment for any kind of esophageal diverticula.
  • Surgical treatment
    • Indications
    • Endoscopy; (rigid or flexible, with the former requiring general anaesthesia) with diverticulostomy and myotomy
    • Open surgery

Diverticula of the middle and distal esophagus (traction diverticula and epiphrenic diverticula) usually do not require treatment!

References:[4][1]

Complications

References:[4]

We list the most important complications. The selection is not exhaustive.