Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Esophageal Diverticula Clinical Presentation

  • Author: Jack Bragg, DO; Chief Editor: Julian Katz, MD  more...
 
Updated: Jun 18, 2014
 

History

Zenker diverticulum

A Zenker diverticulum, which is seen in the images below, is formed by the herniation of mucosa through an area of weakness in the posterior wall of the hypopharynx (the Killian triangle).

Barium esophagram, anteroposterior view, demonstra Barium esophagram, anteroposterior view, demonstrating a bilobed Zenker diverticulum.
Zenker diverticulum, lateral view. Zenker diverticulum, lateral view.

Sometimes Zenker diverticula are called pharyngoesophageal diverticula because of their close proximity to the cervical esophagus; however, this is somewhat of a misnomer because the diverticula actually arise from the hypopharynx rather than from the esophagus. Of the diverticula discussed in this article, Zenker diverticula are the most common type to cause symptoms.

Zenker diverticula are an acquired pulsion-type of diverticula that probably develop because of the aging process. They form in the posterior hypopharynx at a point where a defect in the muscular wall, between the inferior pharyngeal constrictor muscle and the cricopharyngeal sphincter (Killian triangle), usually exists.

Zenker diverticula are believed to occur because of an outflow obstruction caused when loss of coordination of the buccal squirt (ie, swallowing movement of the tongue posteriorly with contraction of the oropharyngeal muscles) and opening of the cricopharyngeus (ie, the upper esophageal sphincter) occurs. The noncompliant cricopharyngeus muscle becomes fibrotic over time.

Killian-Jamieson diverticula originate in the anterolateral wall just below the cricopharyngeus (Killian-Jamieson space).[3]

Oropharyngeal dysphagia, usually to solids and to liquids, is the most common symptom. Retention of food material and secretions in the diverticulum, particularly when diverticula are large, can result in regurgitation of undigested food, halitosis, cough, and even aspiration pneumonia. The patient may note food on the pillow upon awakening in the morning. With very large diverticula, a mass in the neck occasionally can be detected. Cancer rarely has been reported in association with Zenker diverticula.

Esophageal diverticula

Diverticula of the esophageal body are relatively rare. They primarily occur in the middle and distal esophagus (see the image below).

Esophagram demonstrating a dilated tortuous esopha Esophagram demonstrating a dilated tortuous esophagus and a large midesophageal diverticulum.

Diverticula that occur in the distal esophagus, in the lower 6-10 cm, are termed epiphrenic diverticula (see the image below).

Barium esophagram demonstrating an epiphrenic dive Barium esophagram demonstrating an epiphrenic diverticulum.

Diverticula of the mid and distal esophagus may have various etiologies. For instance, some diverticula in the mid esophagus are congenital in origin; others are of the traction variety. With the latter, diverticula develop by traction from contiguous mediastinal inflammation and adenopathy, eg, pulmonary tuberculosis and histoplasmosis. The diverticula that develop by traction and adenopathy usually are asymptomatic.

Retention of undigested food in large diverticula occasionally results in regurgitation, nocturnal cough, and aspiration pneumonia.

Occasional epiphrenic diverticula occur in the setting of long-standing peptic esophagitis and strictures, and they rarely are symptomatic. Other rare causes of diverticula of the mid and distal esophagus include iatrogenic surgical injury to the esophagus and Ehlers-Danlos syndrome (weakness of collagen). Perhaps the most common causes of mid esophageal and epiphrenic diverticula are motility disorders of the esophageal body, including achalasia, diffuse esophageal spasm, and hypertensive lower esophageal sphincter.

Dysphagia is the most common symptom associated with mid esophageal and epiphrenic diverticula, although it usually is related more to the underlying motility disturbance than to the diverticulum per se. However, on occasion, the diverticulum may be responsible for the dysphagia, particularly if it is very large and filled with food or a bezoar. Regurgitation and aspiration may be related to large mid esophageal and epiphrenic diverticula; however, in patients with achalasia, regurgitation and aspiration are more likely to be related to poor esophageal emptying from the underlying motility disturbance (eg, hypertensive lower esophageal sphincter that fails to relax, absence of esophageal body peristalsis).

Esophageal intramural pseudodiverticulosis

Esophageal intramural pseudodiverticulosis, which is seen in the images below, is a very rare condition in which numerous 1- to 4-mm, saccular, flask-shaped outpouchings form in the wall of the esophagus. Pseudodiverticula can number from a few to a hundred or more. This condition can be segmental or diffuse. About 200 cases have been reported in the literature.

Multiple, small, flask-shaped outpouchings charact Multiple, small, flask-shaped outpouchings characteristic of esophageal intramural pseudodiverticulosis.
Esophageal intramural pseudodiverticulosis involvi Esophageal intramural pseudodiverticulosis involving the entire length of the esophagus.

Pseudodiverticula are formed by dilatation of the esophageal submucosal glands that communicate with the esophageal lumen.

Esophageal intraluminal pseudodiverticulosis generally is believed to be an acquired condition. While the precise pathogenesis is uncertain, inflammation and stasis appear to be factors. One hypothesis states that blockage of intramural ducts by inflammatory debris results in dilation of the submucosal glands.

Most patients with esophageal intraluminal pseudodiverticulosis have underlying esophageal strictures or dysmotility of the esophageal body. Esophageal intraluminal pseudodiverticulosis also has been reported as a consequence of corrosive injury to the esophagus, although most patients have associated strictures.

Dysphagia is the most common symptom associated with esophageal intramural pseudodiverticulosis. In most cases, esophageal intraluminal pseudodiverticulosis is related to the associated esophageal stricture or dysmotility.

An isolated case report cited significant bleeding from a distal esophageal diverticulum. The authors speculated that the bleeding resulted from food stasis, bacterial overgrowth, or chronic inflammation.

Next

Physical

Findings on physical examination often are normal in patients with symptomatic esophageal diverticula. However, many patients relate a history of dysphagia, chest pain, or regurgitation.

Although the physical examination findings are often normal, a large Zenker diverticulum may present as a neck mass on physical examination. Halitosis also may be present and is secondary to accumulated food debris or medicines within the diverticulum.

Signs and symptoms of aspiration pneumonia may accompany the presence of large symptomatic diverticula.

Previous
Next

Causes

Most diverticula are caused by an underlying motility disorder of the esophagus. Structural lesions, including a noncompliant cricopharyngeus muscle (ie, Zenker diverticulum), incomplete or uncoordinated relaxation of the lower esophageal sphincter, or strictures, may play a role as well. An underlying inflammatory process within the mediastinum has been associated with mid esophageal diverticula.

Previous
 
 
Contributor Information and Disclosures
Author

Jack Bragg, DO Associate Professor, Department of Clinical Medicine, University of Missouri School of Medicine

Jack Bragg, DO is a member of the following medical societies: American College of Osteopathic Internists, American Osteopathic Association

Disclosure: Nothing to disclose.

Coauthor(s)

John B Marshall, MD Professor, Department of Internal Medicine, Division of Gastroenterology, University of Missouri School of Medicine

John B Marshall, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, Phi Beta Kappa

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Julian Katz, MD Clinical Professor of Medicine, Drexel University College of Medicine

Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law, Medicine & Ethics, American Trauma Society, Association of American Medical Colleges, Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Additional Contributors

Maurice A Cerulli, MD, FACP, FACG, FASGE, AGAF Associate Professor of Clinical Medicine, Albert Einstein College of Medicine of Yeshiva University; Associate Professor of Clinical Medicine, Hofstra Medical School

Maurice A Cerulli, MD, FACP, FACG, FASGE, AGAF is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American College of Physicians, New York Society for Gastrointestinal Endoscopy, American Gastroenterological Association, American Medical Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Acknowledgements

Simmy Bank, MD Chair, Professor, Department of Internal Medicine, Division of Gastroenterology, Long Island Jewish Hospital, Albert Einstein College of Medicine

Disclosure: Nothing to disclose.

Christopher (Kit) Bartalos, DO Fellow, Department of Gastroenterology, University of Missouri at Columbia

Disclosure: Nothing to disclose.

Rodney A Perez, MD Medical Director, The Endoscopy Center, Asheville Gastroenterology Associates; Consulting Staff, Department of Gastroenterology, Mission St Joseph's Hospital

Rodney A Perez, MD is a member of the following medical societies: American Gastroenterological Association

Disclosure: Nothing to disclose.

References
  1. Herbella FA, Patti MG. Modern pathophysiology and treatment of esophageal diverticula. Langenbecks Arch Surg. 2012 Jan. 397(1):29-35. [Medline].

  2. D'Journo XB, Ferraro P, Martin J, Chen LQ, Duranceau A. Lower oesophageal sphincter dysfunction is part of the functional abnormality in epiphrenic diverticulum. Br J Surg. 2009 Aug. 96(8):892-900. [Medline].

  3. Ekberg O, Nylander G. Lateral diverticula from the pharyngo-esophageal junction area. Radiology. 1983 Jan. 146(1):117-22. [Medline].

  4. Kim HK, Lee JI, Jang HW, Bae SY, Lee JH, Kim YS, et al. Characteristics of Killian-Jamieson diverticula mimicking a thyroid nodule. Head Neck. 2012 Apr. 34(4):599-603. [Medline].

  5. Pang JC, Chong S, Na HI, Kim YS, Park SJ, Kwon GY. Killian-Jamieson diverticulum mimicking a suspicious thyroid nodule: sonographic diagnosis. J Clin Ultrasound. 2009 Nov-Dec. 37(9):528-30. [Medline].

  6. Lixin J, Bing H, Zhigang W, Binghui Z. Sonographic diagnosis features of Zenker diverticulum. Eur J Radiol. 2011 Nov. 80(2):e13-9. [Medline].

  7. Vicentine FP, Herbella FA, Silva LC, Patti MG. High resolution manometry findings in patients with esophageal epiphrenic diverticula. Am Surg. 2011 Dec. 77(12):1661-4. [Medline].

  8. Christiaens P, De Roock W, Van Olmen A, et al. Treatment of Zenker's diverticulum through a flexible endoscope with a transparent oblique-end hood attached to the tip and a monopolar forceps. Endoscopy. 2007 Feb. 39(2):137-40. [Medline].

  9. Kos MP, David EF, Mahieu HF. Endoscopic carbon dioxide laser Zenker's diverticulotomy revisited. Ann Otol Rhinol Laryngol. 2009 Jul. 118(7):512-8. [Medline].

  10. Helmstaedter V, Engel A, Huttenbrink KB, Guntinas-Lichius O. Carbon dioxide laser endoscopic diverticulotomy for Zenker's diverticulum: results and complications in a consecutive series of 40 patients. ORL J Otorhinolaryngol Relat Spec. 2009. 71(1):40-4. [Medline].

  11. Visosky AM, Parke RB, Donovan DT. Endoscopic management of Zenker's diverticulum: factors predictive of success or failure. Ann Otol Rhinol Laryngol. 2008 Jul. 117(7):531-7. [Medline].

  12. Wasserzug O, Zikk D, Raziel A, Cavel O, Fleece D, Szold A. Endoscopically stapled diverticulostomy for Zenker's diverticulum: results of a multidisciplinary team approach. Surg Endosc. 2009 Aug 18. [Medline].

  13. Rabenstein T, May A, Michel J, et al. Argon plasma coagulation for flexible endoscopic Zenker's diverticulotomy. Endoscopy. 2007 Feb. 39(2):141-5. [Medline].

  14. Vogelsang A, Preiss C, Neuhaus H, et al. Endotherapy of Zenker's diverticulum using the needle-knife technique: long-term follow-up. Endoscopy. 2007 Feb. 39(2):131-6. [Medline].

  15. Koch M, Mantsopoulos K, Velegrakis S, Iro H, Zenk J. Endoscopic laser-assisted diverticulotomy versus open surgical approach in the treatment of Zenker's diverticulum. Laryngoscope. 2011 Oct. 121(10):2090-4. [Medline].

  16. Adam SI, Paskhover B, Sasaki CT. Laser versus stapler: outcomes in endoscopic repair of Zenker diverticulum. Laryngoscope. 2012 Sep. 122(9):1961-6. [Medline].

  17. Bizzotto A, Iacopini F, Landi R, Costamagna G. Zenker's diverticulum: exploring treatment options. Acta Otorhinolaryngol Ital. 2013 Aug. 33(4):219-29. [Medline]. [Full Text].

  18. Huberty V, El Bacha S, Blero D, Le Moine O, Hassid S, Devière J. Endoscopic treatment for Zenker's diverticulum: long-term results (with video). Gastrointest Endosc. 2013 May. 77(5):701-7. [Medline].

  19. Undavia S, Anand SM, Jacobson AS. Killian-Jamieson diverticulum: a case for open transcervical excision. Laryngoscope. 2013 Feb. 123(2):414-7. [Medline].

  20. Seth R, Rajasekaran K, Lee WT, Lorenz RR, Wood BG, Kominsky A, et al. Patient reported outcomes in endoscopic and open transcervical treatment for Zenker's diverticulum. Laryngoscope. 2014 Jan. 124(1):119-25. [Medline].

  21. American Society for Gastrointestinal Endoscopy. Technology Assessment Status Evaluation: botulinum toxin therapy in gastrointestinal endoscopy. November, 1996. ASGE. American Society for Gastrointestinal Endoscopy. Gastrointest Endosc. 1998 Jun. 47(6):569-72. [Medline].

  22. Bak YT, Kim HJ, Jo NY, et al. Endoscopic "clip and cut" diverticulotomy for a giant midesophageal diverticulum. Gastrointest Endosc. 2003 May. 57(6):777-9. [Medline].

  23. Bassotti G, Annese V. Review article: pharmacological options in achalasia. Aliment Pharmacol Ther. 1999 Nov. 13(11):1391-6. [Medline].

  24. Bowdler DA, Stell PM. Carcinoma arising in posterior pharyngeal pulsion diverticulum (Zenker's diverticulum). Br J Surg. 1987 Jul. 74(7):561-3. [Medline].

  25. Boyce HW Jr, Boyce G. Esophagus: anatomy and structural anomalies. Yamada T, ed. Textbook of Gastroenterology. 4th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2003. 1148-65.

  26. Bremner CG, DeMeester TR. Endoscopic treatment of Zenker's diverticulum. Gastrointest Endosc. 1999 Jan. 49(1):126-8. [Medline].

  27. Cassivi SD, Deschamps C, Nichols FC 3rd, et al. Diverticula of the esophagus. Surg Clin North Am. 2005 Jun. 85(3):495-503, ix. [Medline].

  28. Cook IJ, Gabb M, Panagopoulos V, et al. Pharyngeal (Zenker's) diverticulum is a disorder of upper esophageal sphincter opening. Gastroenterology. 1992 Oct. 103(4):1229-35. [Medline].

  29. Del Genio A, Rossetti G, Maffetton V, et al. Laparoscopic approach in the treatment of epiphrenic diverticula: long-term results. Surg Endosc. 2004 May. 18(5):741-5. [Medline].

  30. Fernando HC, Luketich JD, Samphire J, et al. Minimally invasive operation for esophageal diverticula. Ann Thorac Surg. 2005 Dec. 80(6):2076-80. [Medline].

  31. Fraiji E Jr, Bloomston M, Carey L, et al. Laparoscopic management of symptomatic achalasia associated with epiphrenic diverticulum. Surg Endosc. 2003 Oct. 17(10):1600-3. [Medline].

  32. Hashiba K, de Paula AL, da Silva JG, et al. Endoscopic treatment of Zenker's diverticulum. Gastrointest Endosc. 1999 Jan. 49(1):93-7. [Medline].

  33. Heinen FL, Vallone P, Elmo G. Esophageal diverticulum in an infant with Down's syndrome and type III esophageal atresia. J Pediatr Surg. 2003 Apr. 38(4):E9. [Medline].

  34. Herman TE, McAlister WH. Esophageal diverticula in childhood associated with strictures from unsuspected foreign bodies of the esophagus. Pediatr Radiol. 1991. 21(6):410-2. [Medline].

  35. Herter B, Dittler HJ, Wuttge-Hannig A, et al. Intramural pseudodiverticulosis of the esophagus: a case series. Endoscopy. 1997 Feb. 29(2):109-13. [Medline].

  36. Huang BS, Unni KK, Payne WS. Long-term survival following diverticulectomy for cancer in pharyngoesophageal (Zenker's) diverticulum. Ann Thorac Surg. 1984 Sep. 38(3):207-10. [Medline].

  37. Jeyarajah R, Harford W. Diverticula of the hypopharynx, esophagus, stomach, jejunum, and ileum. Feldman M, Friedman LS, Sleisenger MH, eds. Gastrointestinal and Liver Disease: Pathophysiology, Diagnosis, Management. Philadelphia, Pa: Saunders; 2002. 359-68.

  38. Kimura H, Konishi K, Tsukioka Y, et al. Superficial esophageal carcinoma arising from the diverticulum of the esophagus. Endoscopy. 1997 Nov. 29(9):S53-4. [Medline].

  39. Knapp AB, Ladetsky L. Endoscopic retrieval of a small bowel enteroscopy capsule lodged in a Zenker's diverticulum. Clin Gastroenterol Hepatol. 2005 May. 3(5):xxxiv. [Medline].

  40. Kochhar R, Mehta SK, Nagi B, et al. Corrosive acid-induced esophageal intramural pseudodiverticulosis. A study of 14 patients. J Clin Gastroenterol. 1991 Aug. 13(4):371-5. [Medline].

  41. Long JD, Orlando RC. Esophageal submucosal glands: structure and function. Am J Gastroenterol. 1999 Oct. 94(10):2818-24. [Medline].

  42. Mahajan RJ, Marshall JB. Severe dysphagia, dysmotility, and unusual saccular dilation (diverticulum) of the esophagus following excision of an asymptomatic congenital cyst. Am J Gastroenterol. 1996 Jun. 91(6):1254-8. [Medline].

  43. Mahajan SK, Warshauer DM, Bozymski EM. Esophageal intramural pseudo-diverticulosis: endoscopic and radiologic correlation. Gastrointest Endosc. 1993 Jul-Aug. 39(4):565-7. [Medline].

  44. Medeiros LJ, Doos WG, Balogh K. Esophageal intramural pseudodiverticulosis: a report of two cases with analysis of similar, less extensive changes in "normal" autopsy esophagi. Hum Pathol. 1988 Aug. 19(8):928-31. [Medline].

  45. Motoyama S, Maruyama K, Okuyama M, et al. Laparoscopic long esophagomyotomy with Dor's fundoplication using a transhiatal approach for an epiphrenic esophageal diverticulum. Surg Today. 2006. 36(8):758-60. [Medline].

  46. Sam AD Jr, Chaer RA, Cintron J, et al. Upper gastrointestinal bleeding caused by a "hypophrenic" diverticulum of the distal esophagus. Am Surg. 2005 Apr. 71(4):333-5. [Medline].

  47. Tedesco P, Fisichella PM, Way LW, et al. Cause and treatment of epiphrenic diverticula. Am J Surg. 2005 Dec. 190(6):891-4. [Medline].

  48. Tobin RW. Esophageal rings, webs, and diverticula. J Clin Gastroenterol. 1998 Dec. 27(4):285-95. [Medline].

  49. Toyohara T, Kaneko T, Araki H, et al. Giant epiphrenic diverticulum in a boy with Ehlers-Danlos syndrome. Pediatr Radiol. 1989. 19(6-7):437. [Medline].

 
Previous
Next
 
Barium esophagram, anteroposterior view, demonstrating a bilobed Zenker diverticulum.
Zenker diverticulum, lateral view.
Esophagram demonstrating a dilated tortuous esophagus and a large midesophageal diverticulum.
Barium esophagram demonstrating an epiphrenic diverticulum.
Multiple, small, flask-shaped outpouchings characteristic of esophageal intramural pseudodiverticulosis.
Esophageal intramural pseudodiverticulosis involving the entire length of the esophagus.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.