Updated: 12/20/2019

Zenker Diverticulum

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https://upload.medbullets.com/topic/120142/images/zenker_s_diverticulum_ba_swallow_ento_076.jpg
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)
  • 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
Studies 
  • Diagnostic testing
    • diagnostic approach
      • diagnosis is based on clinical history and physical exam and confirmed via barium esophagram
    • 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
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
Treatment
  • Management approach
    • the mainstay of treatment of symptomatic Zenker diverticula is surgery
    • if the diverticulum is small and asymptomatic, then no treatment is necessary
  • First-line
    • myotomy of cricopharyngeus muscle with diverticulum resection
      • endoscopic approach has better success rates compared to external approach
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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