Review Question - QID 104554

This patient is experiencing a Zenker's diverticulum (ZD). Clinical observations, history, and a barium swallow study are the keys needed to make this diagnosis.

Zenker's diverticulum is a condition characterized by a false diverticula of the esophagus. The pathophysiology of this condition includes a pulsion diverticula involving only the mucosa of the esophagus. It is often located at the junction of the pharynx and esophagus where there is an area of weakness involving the cricopharyngeus muscle. Symptoms include dysphagia, regurgitation, and choking. Physical examination can sometimes show a neck mass, but will often include halitosis secondary to trapped food particles.

Law et al. discuss Zenker's diverticula (ZD). ZD is an outpouching of tissue through the Killian triangle that is thought to be caused by dysfunction of the cricopharyngeal muscle. This pathology, although uncommon, most often takes place in the elderly. Pulmonary aspiration is one of the most serious and feared consequences of ZD.

Constantin et al. report on the surgical treatment of ZD. There are varying attitudes concerning ZD when it comes to management. Management ranges from conservative therapies to surgical procedures (with associated morbidity and mortality). Diverticulectomy has been shown to be the most efficient method of alleviating dysphagia compared with the simple myotomy or myotomy associated with diverticulopexy. Although ZD has a “benign” pathology, when it requires surgical intervention, the complex surgical procedures imply a significant morbidity rate.

Illustration A is a lateral view of a barium study showing a Zenker's diverticulum. Illustration B is an artists rendition of a diverticulectomy. Illustration C is an artists rendition of a diverticulopexy.

Incorrect Answers:
Answer 1: Although necessary, clinical observations and history alone are not the appropriate way to diagnose a Zenker's diverticulum. Barium swallow studies are also necessary for confirmation of clinical suspicion.
Answer 2: Upper endoscopy is not used in the diagnosis of Zenker's diverticula.
Answer 3: Although a chest radiograph would be used in the overall workup, in order to diagnosis Zenker's diverticula, a barium swallow study must be performed.
Answer 5: Manometry would be the appropriate choice for a younger patient experiencing dysphagia that also perhaps some regurgitation but less fetid breath in the case of achalasia. The demographics of this case better fit ZD