Epidemiology

• Peak incidence: older male individuals (70-80 y)
• Zenker diverticulum is the most common type.

Etiology

Pathophysiology

• Inadequate relaxation of the esophageal sphincter (e.g., caused by achalasia or spastic motility) and increased intraluminal pressure → outpouching of the esophageal wall → pulsion diverticulum
  • Usually a false diverticulum
  • Common sites
    • Upper esophageal sphincter (UES) → pharyngoesophageal pulsion diverticulum (e.g., Zenker diverticulum, between the thyropharyngeal and cricopharyngeal)
    • Lower esophageal sphincter (LES) → epiphrenic pulsion diverticulum
• Inflammation of the mediastinum with scarring and retraction (e.g., secondary to tuberculosis or fungal infection) → traction diverticulum
  • Usually true diverticulum
  • Common site: the middle esophagus

Clinical features

• Upper esophageal diverticula (e.g., Zenker diverticulum)
• Most patients report some degree of dysphagia.
• Additional symptoms can include:
  • Regurgitation of undigested food
  • Halitosis
    • Originating from food or medicine retained within the diverticulum
  • Aspiration pneumonia
  • Dysphonia
  • Coughing after ingesting food
  • Retrosternal pressure sensation and pain
  • Weight loss
  • Neck mass (only with large upper esophageal diverticula)

Diagnostics

• Barium swallow with videofluoroscopy (best initial test)

Treatment