Академический Документы
Профессиональный Документы
Культура Документы
Disclosure
INTRODUCTION Section 2 of 11
Author Information Introduction Clinical Differentials Workup Treatment
Medication Follow-up Miscellaneous Pictures Bibliography
CLINICAL Section 3 of 11
Author Information Introduction Clinical Differentials Workup Treatment
Medication Follow-up Miscellaneous Pictures Bibliography
History:
Zenker diverticula (see Images 1-2) are formed by the herniation of mucosa
through an area of weakness in the posterior wall of the hypopharynx (the Killian
triangle).
Sometimes Zenker diverticula are called pharyngoesophageal diverticula
because of their close proximity to the cervical esophagus; however, this is
somewhat of a misnomer because the diverticula actually arise from the
hypopharynx rather than from the esophagus.
Of the diverticula discussed in this article, Zenker diverticula are the most
common type to cause symptoms.
Zenker diverticula are an acquired pulsion-type of diverticula that probably
develop because of the aging process. They form in the posterior hypopharynx at
a point where a defect in the muscular wall, between the inferior pharyngeal
constrictor muscle and the cricopharyngeal sphincter (Killian triangle), usually
exists.
Zenker diverticula are believed to occur because of an outflow obstruction
caused when loss of coordination of the buccal squirt (ie, swallowing movement
of the tongue posteriorly with contraction of the oropharyngeal muscles) and
opening of the cricopharyngeus (ie, the upper esophageal sphincter) occurs. The
noncompliant cricopharyngeus muscle becomes fibrotic over time.
Zenker diverticula typically present in people older than 50 years and especially
present during the seventh and eighth decades of life.
Oropharyngeal dysphagia, usually to solids and to liquids, is the most common
symptom. Retention of food material and secretions in the diverticulum,
particularly when diverticula are large, can result in regurgitation of undigested
food, halitosis, cough, and even aspiration pneumonia. The patient may note
food on the pillow upon awakening in the morning. With very large diverticula, a
mass in the neck occasionally can be detected. Cancer rarely has been reported
in association with Zenker diverticula.
Diverticula of the esophageal body are relatively rare. They primarily occur in
the middle and distal esophagus (see Image 3).
Diverticula that occur in the distal esophagus, in the lower 6-10 cm, are termed
epiphrenic diverticula (see Image 4).
Diverticula of the mid and distal esophagus may have various etiologies. For
instance, some diverticula in the mid esophagus are congenital in origin; others
are of the traction variety. With the latter, diverticula develop by traction from
contiguous mediastinal inflammation and adenopathy, eg, pulmonary
tuberculosis and histoplasmosis. The diverticula that develop by traction and
adenopathy usually are asymptomatic.
Retention of undigested food in large diverticula occasionally results in
regurgitation, nocturnal cough, and aspiration pneumonia.
Occasional epiphrenic diverticula occur in the setting of long-standing peptic
esophagitis and strictures, and they rarely are symptomatic. Other rare causes of
diverticula of the mid and distal esophagus include iatrogenic surgical injury to
the esophagus and Ehlers-Danlos syndrome (weakness of collagen). Perhaps
the most common causes of mid esophageal and epiphrenic diverticula are
motility disorders of the esophageal body, including achalasia, diffuse
esophageal spasm, and hypertensive lower esophageal sphincter.
Dysphagia is the most common symptom associated with mid esophageal and
epiphrenic diverticula, although it usually is related more to the underlying motility
disturbance than to the diverticulum per se. However, on occasion, the
diverticulum may be responsible for the dysphagia, particularly if it is very large
and filled with food or a bezoar. Regurgitation and aspiration may be related to
large mid esophageal and epiphrenic diverticula; however, in patients with
achalasia, regurgitation and aspiration are more likely to be related to poor
esophageal emptying from the underlying motility disturbance (eg, hypertensive
lower esophageal sphincter that fails to relax, absence of esophageal body
peristalsis).
Esophageal intramural pseudodiverticulosis is a very rare condition in which
numerous 1- to 4-mm, saccular, flask-shaped outpouchings form in the wall of
the esophagus (see Images 5-6). Pseudodiverticula can number from a few to a
hundred or more. This condition can be segmental or diffuse. About 200 cases
have been reported in the literature.
Pseudodiverticula are formed by dilatation of the esophageal submucosal glands
that communicate with the esophageal lumen.
Esophageal intraluminal pseudodiverticulosis generally is believed to be an
acquired condition. While the precise pathogenesis is uncertain, inflammation
and stasis appear to be factors. One hypothesis states that blockage of
intramural ducts by inflammatory debris results in dilation of the submucosal
glands.
Most patients with esophageal intraluminal pseudodiverticulosis have underlying
esophageal strictures or dysmotility of the esophageal body. Esophageal
intraluminal pseudodiverticulosis also has been reported as a consequence of
corrosive injury to the esophagus, although most patients have associated
strictures.
Dysphagia is the most common symptom associated with esophageal intramural
pseudodiverticulosis. In most cases, esophageal intraluminal
pseudodiverticulosis is related to the associated esophageal stricture or
dysmotility.
An isolated case report recently cited significant bleeding from a distal
esophageal diverticulum. The authors speculate the bleeding resulted from food
stasis, bacterial overgrowth, or chronic inflammation.
Physical:
Achalasia
Esophageal Cancer
Esophageal Motility Disorders
Esophageal Spasm
Esophageal Stricture
Gastroesophageal Reflux Disease
Zenker Diverticulum
Quick Find
Author Information
Introduction
Clinical
Differentials
Workup
Treatment
Medication
Follow-up
Miscellaneous
Pictures
Bibliography
Related Articles
Achalasia
Esophageal Cancer
Esophageal Spasm
Esophageal Stricture
Zenker Diverticulum
Patient Education
Esophagus, Stomach, and Intestine Center
Lab Studies:
Most laboratory studies are not helpful in the diagnosis. (Upper esophageal webs
have been associated with iron deficiency anemia.)
Imaging Studies:
Medical Care:
MEDICATION Section 7 of 11
Author Information Introduction Clinical Differentials Workup Treatment
Medication Follow-up Miscellaneous Pictures Bibliography
Complications:
Medical/Legal Pitfalls:
Diverticula of the esophagus may be associated with motility disorders or
structural disorders of the esophagus, such as strictures. In a patient with a
known esophageal diverticulum, only experienced endoscopists should perform
esophageal dilation for strictures. Esophageal dilation can be performed safely
by several different means.
The use of through-the-scope dilating balloon catheters is an effective way to
dilate esophageal strictures while maintaining a full endoscopic view during
dilation.
Similarly, guide wireassisted dilation with polyvinyl dilators, with or without the
use of fluoroscopy, allows for added safety during esophageal dilation in patients
with esophageal diverticula.
Blind passage of mercury-filled rubber bougies (Maloney dilators) probably
should not be performed because of the possibility of the dilator entering the
diverticula with subsequent perforation. Similarly, nasogastric tubes or other
nasoenteric devices are best passed with the aid of either endoscopy or
fluoroscopy for the same reasons.
PICTURES Section 10 of 11
Author Information Introduction Clinical Differentials Workup Treatment
Medication Follow-up Miscellaneous Pictures Bibliography