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Esophageal Diverticulum – Causes, Symptoms & Treatment

An esophageal diverticulum is a pouch-like protrusion of the esophageal wall. It can cause difficulty swallowing, regurgitation, and coughing, and is treated conservatively or surgically depending on severity.

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Things worth knowing about "Esophageal Diverticulum"

An esophageal diverticulum is a pouch-like protrusion of the esophageal wall. It can cause difficulty swallowing, regurgitation, and coughing, and is treated conservatively or surgically depending on severity.

What Is an Esophageal Diverticulum?

An esophageal diverticulum is an abnormal, pouch-like outpouching of the wall of the esophagus (the tube connecting the throat to the stomach). Food particles and mucus can collect in this pouch, leading to a variety of symptoms. Diverticula can occur at different locations along the esophagus and are classified by their position and underlying mechanism of formation.

Types of Esophageal Diverticula

Zenker Diverticulum

The Zenker diverticulum is the most common type and forms at the junction between the pharynx and the esophagus (pharyngoesophageal junction). It is a pulsion diverticulum, meaning it develops due to increased internal pressure when the upper esophageal sphincter fails to relax properly during swallowing.

Mid-Esophageal (Traction) Diverticulum

These diverticula occur near the tracheal bifurcation (the point where the windpipe splits into two bronchi) and are often caused by inflammatory processes in surrounding lymph nodes, such as in tuberculosis. They are called traction diverticula because they are pulled outward by external forces from scarred tissue.

Epiphrenic Diverticulum

An epiphrenic diverticulum develops in the lower portion of the esophagus, just above the diaphragm. Like the Zenker diverticulum, it is a pulsion type and is frequently associated with esophageal motility disorders such as achalasia or diffuse esophageal spasm.

Causes

The development of esophageal diverticula is influenced by several factors:

Increased intraluminal pressure due to impaired coordination of esophageal muscles (pulsion diverticula)
External traction forces from scarred lymph nodes or inflammatory conditions (traction diverticula)
Esophageal motility disorders, particularly achalasia or esophageal spasm
Connective tissue weakness of the esophageal wall
Advanced age as a predisposing factor

Symptoms

Small diverticula often cause no symptoms and are discovered incidentally. Larger diverticula may produce the following symptoms:

Dysphagia (difficulty swallowing)
Regurgitation of undigested food or fluid
Chronic coughing or the need to clear the throat frequently
Halitosis (bad breath) due to fermented food particles trapped in the pouch
Sensation of a lump or foreign body in the throat
Unintentional weight loss in severe cases
In rare cases: aspiration of food into the lungs, leading to pneumonia

Diagnosis

Several diagnostic methods are used to identify esophageal diverticula:

Barium swallow study (esophagography): The gold-standard imaging test in which the patient swallows a contrast agent and X-ray images are taken. Diverticula are clearly visible in these images.
Endoscopy (esophagoscopy): Allows direct visualization of the esophageal lining. Special caution is required in the presence of a Zenker diverticulum to avoid perforation.
CT scan of the chest: Provides additional detail about the size, location, and relationship of the diverticulum to surrounding structures.
Esophageal manometry: Measures pressure within the esophagus to detect underlying motility disorders that may have caused the diverticulum.

Treatment

Conservative Management

Small, asymptomatic diverticula often require no treatment. Regular monitoring is recommended along with dietary modifications such as eating slowly, chewing thoroughly, and drinking plenty of fluids with meals to flush out the pouch.

Endoscopic Treatment

For Zenker diverticula, endoscopic septotomy -- the division of the wall (septum) between the diverticulum and the esophageal lumen -- is a well-established, minimally invasive procedure. It can be performed using a rigid or flexible endoscope and has high success rates with low complication rates.

Surgical Treatment

Large or severely symptomatic diverticula that are not amenable to endoscopic treatment require surgical intervention. The standard approach involves diverticulectomy (removal of the pouch) often combined with a myotomy (surgical cutting of the affected sphincter muscle) to reduce pressure and prevent recurrence.

Complications

If left untreated or if the diverticulum enlarges, serious complications may arise:

Aspiration pneumonia: Inhalation of food particles into the lungs
Perforation: Spontaneous or procedure-related rupture of the diverticulum
Malignant transformation: In very rare cases, carcinoma may develop within a long-standing diverticulum

References

Patti MG, Gantert W, Way LW: Surgery of the esophagus. In: Surgical Clinics of North America, 1997.
Spiess AE, Kahrilas PJ: Treating achalasia -- from whalebone to laparoscope. In: JAMA, 1998.
Richter JE: Oesophageal motility disorders. In: The Lancet, 2001.

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