eMedicine Specialties > Gastroenterology > Esophagus

Esophageal Diverticula: Treatment & Medication

Author: Jack Bragg, DO, FACOI, Assistant Professor, Department of Clinical Medicine, University of Missouri School of Medicine
Coauthor(s): Christopher (Kit) Bartalos, DO, Fellow, Department of Gastroenterology, University of Missouri at Columbia; Rodney A Perez, MD, Medical Director, The Endoscopy Center, Asheville Gastroenterology Associates; Consulting Staff, Department of Gastroenterology, Mission St Joseph's Hospital; John B Marshall, MD, Professor, Department of Internal Medicine, Division of Gastroenterology, University of Missouri School of Medicine
Contributor Information and Disclosures

Updated: Sep 2, 2008

Treatment

Medical Care

  • Asymptomatic and minimally symptomatic esophageal body diverticula do not require treatment.
  • In many patients with mid esophageal and epiphrenic diverticula, dysphagia is related to underlying dysmotility; thus, treatment should be directed to the motility disorder when feasible. For instance, achalasia can be treated with pneumatic dilation, botulinum toxin injection into the lower esophageal sphincter, or surgical Heller esophagomyotomy.
  • Treatment of esophageal intramural pseudodiverticulosis is directed toward underlying strictures or dysmotility.

Surgical Care

Treatment of Zenker diverticulum traditionally has been surgical, although the specific operation used still is controversial. Surgical options include diverticulectomy with cricopharyngeal myotomy, diverticular suspension (diverticulopexy) with cricopharyngeal myotomy, and cricopharyngeal myotomy alone.

  • Consider diverticulectomy when esophageal body diverticula are believed to be the cause of aspiration. An abdominal laparoscopic approach may be feasible for some patients with epiphrenic diverticula. Case reports of endoscopic treatment of giant midesophageal diverticula have been reported. However, patients who are being considered for diverticulectomy should first undergo careful study with barium swallow, flexible endoscopy, and esophageal manometry. Treatment directed at an underlying esophageal motility disorder, such as achalasia, cannot be ignored.
  • Diverticulectomy usually is not performed by itself because it does not correct the defect in cricopharyngeal function that usually contributes to the formation of a Zenker diverticulum.
    • While the transcervical approach has been used traditionally, the transoral route using a rigid esophagoscope also may be used.
    • Good results have been obtained by performing a diverticulotomy using a flexible endoscope and needle-knife papillotome to cut the common wall between the diverticulum and the oropharynx as well as the cricopharyngeus while the patient is consciously sedated. Recent data suggest that this technique offers good results with a relatively high success rate, but it should be performed in large centers with surgeons who are experienced with this technique.  In some variations of this technique, the diverticulum is stapled.
    • Other novel techniques are being developed. Flexible endoscopic diverticulotomy approaches have been explored using various techniques, including argon plasma coagulation, monopolar coagulation forceps, and needle-knife incision. These techniques typically use a cap or hood attached to the endoscope. The goal of these techniques is the division of the septum between the diverticulum and the esophagus, thus performing a cricopharyngeal myotomy. 
    • Within the last few years, increased efforts to a laparoscopic approach to repair both epiphrenic diverticula and Zenker diverticula have been explored. The literature supports both open surgery and a laparoscopic approach as appropriate methods of repair. The laparoscopic technique uses stapler closure, and multiple case reports cite wound leakage from stapler failure as a complication. With complication rates as high as 20%, a skilled surgeon with experience in this procedure is beneficial. Benefits of the laparoscopic approach include decreased morbidity because of no thoracotomy wounds and chest tubes and a less invasive approach.

Consultations

  • Gastroenterologist - For patients who have symptoms associated with esophageal diverticula or who have esophageal motility disorders, such as achalasia.
  • General or thoracic surgeon (with experience) after gastroenterological evaluation - For patients who have significant symptoms associated with Zenker diverticulum, achalasia, or diverticula.

Medication

Botulinum toxin has been used successfully as an alternative to surgical myotomy or pneumatic dilation for the treatment of achalasia.

Neuromuscular blocker agents

May relax smooth muscle.


Botulinum toxin A (BOTOX®)

Botulinum toxin type A is produced by Clostridium botulinum and is responsible for botulism in humans. Botulinum toxin type A produces denervation of affected muscle tissue by irreversibly binding to presynaptic nerve endings and inhibiting the release of acetylcholine.
When endoscopically injected into the lower esophageal sphincter (LES), interference with cholinergic transmission of the myenteric plexus leads to smooth muscle relaxation with a subsequent fall of the LES resting pressure. This drug has been used in other fields of medicine to treat spastic torticollis and blepharospasm.

Adult

80 U injected into squamocolumnar junction under direct endoscopic visualization; 5-mm injector or sclerotherapy needle used to infiltrate 20 U in 4 quadrants

Pediatric

<12 years: Not established
>12 years: Administer as in adults

Aminoglycosides or drugs that interfere with neuromuscular transmission may potentiate effects of botulinum toxin

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

May cause diffuse skin rash, chest pain, or heartburn; do not exceed recommended dosages and frequencies of administration; presence of antibodies to botulinum toxin type A may reduce effects of therapy

More on Esophageal Diverticula

Overview: Esophageal Diverticula
Differential Diagnoses & Workup: Esophageal Diverticula
Treatment & Medication: Esophageal Diverticula
Follow-up: Esophageal Diverticula
Multimedia: Esophageal Diverticula
References
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Further Reading

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Keywords

esophageal diverticula, esophageal diverticulum, Zenker diverticulum, Zenker's diverticulum, pharyngoesophageal diverticula, hypopharynx, congenital esophageal diverticulum, acquired esophageal diverticulum, diverticulum of the esophageal body, true esophageal diverticula, false esophageal diverticula, pseudodiverticula of the esophagus, esophageal intramural pseudodiverticulosis, pulsion diverticula of the esophagus, traction diverticula of the esophagus, dysphagia, epiphrenic diverticula, regurgitation, nocturnal cough, aspiration pneumonia, Ehlers-Danlos syndrome

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Contributor Information and Disclosures

Author

Jack Bragg, DO, FACOI, Assistant Professor, Department of Clinical Medicine, University of Missouri School of Medicine
Jack Bragg, DO, FACOI is a member of the following medical societies: American College of Osteopathic Internists and American Osteopathic Association
Disclosure: Nothing to disclose.

Coauthor(s)

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.

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 College of Physicians, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, American Urological Association, Central Society for Clinical Research, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Medical Editor

Maurice A Cerulli, MD, FACG, Chief, Division of Gastroenterology and Hepatology, Associate Professor of Clinical Medicine, Department of Internal Medicine, Division of Gastroenterology, New York Methodist Hospital, Cornell University
Maurice A Cerulli, MD, FACG is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, American Medical Association, and American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

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.

CME Editor

Alex J Mechaber, MD, FACP, Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
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 and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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