Esophageal diverticula

Epidemiology

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

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Etiology

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Pathophysiology

• Classified by location and mechanism (pulsion vs. traction)
• Zenker Diverticulum (Pharyngoesophageal)
  • Most common type
  • Pulsion diverticulum (↑ intraluminal pressure)
  • Location: Killian triangle (between thyropharyngeus and cricopharyngeus muscles) - posterior hypopharynx
  • Pathophysiology: Failure of cricopharyngeus muscle relaxation → ↑ pressure → herniation through weak point
  • False diverticulum (mucosa/submucosa only, no muscle layer)
• Traction Diverticulum (Mid-esophageal)
  • Less common
  • Caused by external pulling forces (e.g., mediastinal inflammation, granulomatous disease like TB or histoplasmosis)
  • Location: Mid-esophagus near carina
  • True diverticulum (all layers of esophageal wall)
  • Usually asymptomatic
• Epiphrenic Diverticulum (Distal esophageal)
  • Pulsion diverticulum
  • Location: Distal 10 cm of esophagus (above LES)
  • Associated with esophageal motility disorders (achalasia, diffuse esophageal spasm)

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Clinical features

• Zenker: Dysphagia, halitosis, regurgitation of undigested food, gurgling sounds, neck mass, aspiration risk c
• Traction: Often asymptomatic
• Epiphrenic: Dysphagia, chest pain, regurgitation

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Diagnostics

• Barium swallow with videofluoroscopy (best initial test)

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Treatment

• Zenker’s Diverticulum (Symptomatic):
  1. Surgery: Treatment of choice.
     • Cricopharyngeal myotomy (essential to relieve the high-pressure outflow obstruction).
     • Combined with diverticulectomy (excision of pouch) or diverticulopexy (suspension of pouch to prevent food stasis).
     • Can be performed via open cervical approach or minimally invasive endoscopic stapling (rigid or flexible).
  2. Asymptomatic Zenker’s: Observation/conservative monitoring if small (<2 cm).
• Mid-esophageal & Epiphrenic Diverticula:
  1. First-line: Treat the underlying etiology (e.g., anti-mycobacterial therapy for active TB; myotomy/balloon dilation for underlying motility disorders like achalasia).
  2. Surgical Excision: Reserved for severe, refractory symptoms (dysphagia, severe chest pain, recurrent aspiration).

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