Updated: 12/11/2021

Zenker Diverticulum

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  • Snapshot
    • A 73-year-old female is being seen at the emergency department after having recurrent coughing spells and regurgitation following meal. Her husband reports that the symptoms have been occurring over a year and has recently gotten worse. She denies any fever, chest pain, dyspnea, or abdominal pain but endorses a 10-lb. weight loss over the past 3 months. A medical history is significant for hypertension that is controlled with lisinopril. A physical examination demonstrates a palpable, fluctuant neck mass on physical examination and halitosis.
  • Introduction
    • Clinical definition
      • false diverticula (sac-like outpouching of only the mucosa and submucosa) of the esophagus
        • true diverticula contain all layers of the intestinal wall
  • Epidemiology
    • Incidence
      • estimated at 2 per 100,000 a year
    • Demographics
      • 1.5:1 male predominance
      • typically seen in middle-aged adults and older adults in 7th or 8th decade of life
    • Location
      • occurs at the upper part of the esophagus at Killian triangle (an area of muscular weakness between the cricopharyngeus muscle and lower inferior constriction)
  • ETIOLOGY
    • Pathogenesis
      • Killian triangle is a natural area of weakness within the muscular wall of the esophagus and is more common in men
      • thought to result from chronic increased pressure on the weakened area due to either
        • high intrabolus pressures during swallowing
        • resistance to swallowing due to abnormalities of the upper esophageal sphincter
  • Presentation
    • Symptoms
      • dysphagia
      • regurgitation
      • choking
      • chronic cough
      • bad breath (halitosis)
    • Physical exam
      • palpable, fluctuant neck mass may be appreciable
  • Imaging
    • Barium swallow
      • gold standard of diagnosis
      • will demonstrate dye collection posterior to the esophagus
    • Transcutaneous ultrasound
      • allows for differentiation from a thyroid/neck mass
      • good alternative for people who have difficulties swallowing barium
    • Esophageal manometry
      • not required for diagnosis
      • may help to delineate the pathogenesis of the diverticulum
  • Studies
    • Diagnostic testing
      • diagnostic approach
        • diagnosis is based on clinical history and physical exam and confirmed via barium esophagram
  • Differential
    • Achalasia
      • distinguishing factor
        • will demonstrate a bird’s beak on barium swallow
    • Diffuse esophageal spasm
      • distinguishing factor
        • will have characteristic findings on esophageal manometry
  • Complications
    • Aspiration pneumonia
    • Squamous cell carcinoma of the diverticulum
      • prevalence ranges from 0.3-7.0 %
    • Ulceration and bleeding
    • Increased risk of iatrogenic perforation
      • should avoid endoscopy if there is clinical suspicion of Zenker diverticulum

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