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Esophageal Diverticula Workup

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

Laboratory Studies

Most laboratory studies are not helpful in the diagnosis. (Upper esophageal webs have been associated with iron deficiency anemia.)


Imaging Studies

Radiographic studies and upper GI endoscopy detect many esophageal diverticula incidentally because esophageal diverticula often are asymptomatic. On standard chest radiographs and CT scans, large diverticula of the esophagus and hypopharynx also may manifest as air-filled and/or fluid-filled structures communicating with the esophagus.

Barium radiography (ie, barium esophagography, barium swallow) generally is the diagnostic procedure of choice. In addition to being excellent at defining the structural appearance of diverticula, barium swallow also may provide clues to underlying motility disturbances that may be involved in diverticular formation. However, if the patient has dysphagia or odynophagia or has alarm symptoms, then upper endoscopy is indicated.

Barium swallow is a useful study in patients who are symptomatic and have mid esophageal and epiphrenic diverticula. Diagnosis of esophageal intramural pseudodiverticulosis is made best using barium radiography. Diagnosis of Zenker diverticulum is made best using barium swallow, which should include lateral views of the pharyngoesophageal junction. It also can be made using careful upper endoscopy by an experienced endoscopist.

Some reports have described Killian-Jamieson diverticula being detected on ultrasonography of the thyroid gland.[4] Because of the proximity of the upper esophagus to the thyroid gland, pharyngoesophageal diverticula may mimic thyroid nodules on thyroid ultrasonography.[5] A Zenker diverticulum reportedly can be distinguished from a thyroid nodule on ultrasound by the sign of air in the diverticulum.[6]


Other Tests

Esophageal manometry can be helpful to evaluate lower esophageal sphincter pressure, lower esophageal sphincter relaxation, and esophageal body function in symptomatic patients if achalasia or another esophageal motility disorder is suspected or if surgery is being considered. It can also demonstrate the incoordination between the buccal squirt and relaxation of the cricopharyngeus, although special manometric techniques are usually required. In patients with dysphagia, esophageal manometry is helpful to better define underlying motility disorders.

High-resolution manometry (HRM) is a variant of the conventional manometry in which multiple recording sites are used, thus creating a “map” of the esophageal contractions. This technology allows detection of segmental peristaltic defects, detecting motor defects in a higher number of patients with epiphrenic diverticula. One recent study reported finding motor abnormalities in nine people with epiphrenic diverticula.[7]



Perform esophagogastroduodenoscopy to rule out structural conditions of the esophagus, such as strictures or neoplasms, that have been associated with esophageal diverticula.

Flexible endoscopy is a useful study in patients who are symptomatic and have mid esophageal and epiphrenic diverticula.[8, 9, 10, 11] Endoscopy is unnecessary in a patient with Zenker diverticula if the diagnosis has been made using barium radiograph. If flexible upper GI endoscopy is needed in a patient with a known Zenker diverticulum, it should be performed with caution, with the endoscope being passed under direct visualization to minimize the risk of perforation.

Contributor Information and Disclosures

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.


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.


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.

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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.
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