Esophageal diverticula

Esophageal diverticula are abnormal pouches that arise from the wall of the esophagus. They most commonly occur in older men and are classified based on localization, pathophysiology, and histological findings. The most common type of esophageal diverticulum is a posterior outpouching of the hypopharynx, commonly referred to as a Zenker diverticulum. Esophageal diverticula are caused by either an underlying motility disorder that exerts high intraluminal pressure on a weak esophageal wall or forces pulling on the outside of the esophagus. The clinical presentation varies with pouch size and localization, with the most common symptoms being dysphagia, regurgitation, retrosternal pain, and pulmonary symptoms secondary to aspiration. The diagnosis is confirmed by barium swallow. Surgical treatment is rarely required and only recommended in symptomatic patients (primarily those with Zenker diverticulum).

• Rare diverticula compared to other gastrointestinal sites ^[1]
• Peak incidence: older male individuals ^[2]
• Zenker diverticulum is the most common type. ^[3]

Epidemiological data refers to the US, unless otherwise specified.

Esophageal diverticula are classified according to their localization, histology, and pathophysiology. ^[1]

Localization

• Upper esophageal diverticulum
  • Pharyngoesophageal diverticulum
  • Most common type: Zenker diverticulum at the Killian triangle (a triangular weak point in the dorsal muscular wall of the hypopharynx, between the thyropharyngeal and cricopharyngeal parts of the inferior pharyngeal constrictor muscle) ^[4]
• Middle esophageal diverticulum: diverticulum at the tracheal bifurcation
• Lower esophageal diverticulum: epiphrenic diverticulum

Zenker diverticulum arises from the hypopharynx but is classified as an esophageal diverticulum.

Histology ^[2]

• True diverticula: All layers of the esophageal wall protrude.
• False diverticula: Increased intraluminal pressure causes only the mucosa and submucosa to bulge through weak points in the muscularis (e.g., in Zenker diverticulum).

Pathophysiology

• Pulsion diverticula
• Traction diverticula
• See “Pathophysiology” for more information.

• 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 ^[5]
  • Common sites
    • Upper esophageal sphincter (UES) → pharyngoesophageal pulsion diverticulum (e.g., Zenker diverticulum)
    • Lower esophageal sphincter (LES) → epiphrenic pulsion diverticulum ^[1]
• Inflammation of the mediastinum with scarring and retraction (e.g., secondary to tuberculosis or fungal infection) → traction diverticulum ^[5]
  • Usually true diverticulum
  • Common site: the middle esophagus

Symptoms arise if a diverticulum becomes large enough to retain food and/or saliva.

• Upper esophageal diverticula (e.g., Zenker diverticulum)
  • Most patients report some degree of dysphagia.
  • Additional symptoms can include:
    • Regurgitation of undigested food
    • Halitosis
    • Aspiration pneumonia
    • Dysphonia
    • Coughing after ingesting food
    • Retrosternal pressure sensation and pain
    • Weight loss
    • Neck mass (only with large upper esophageal diverticula)
• Middle esophageal and epiphrenic diverticula
  • Patients usually remain asymptomatic. ^[1][5]
  • Associated symptoms are often attributable to the underlying disorder (e.g., achalasia causing chest pain and/or dysphagia). ^[2]

Older MIKE has bad breath: Older, Male individuals, Inferior pharyngeal constrictor, Killian triangle, Esophageal dysmotility, halitosis.

Obtain imaging studies to diagnose esophageal diverticula in patients with supportive clinical features. Based on initial findings, consider endoscopy and esophageal manometry to identify concomitant esophageal disorders.

Imaging studies ^[2]

• Barium swallow with videofluoroscopy (best initial test)
  • Diagnostic finding: a contrast-filled pouch protruding from the esophageal wall
  • Additional findings may include:
    • Tumors
    • Esophageal motility disorder
• Transcutaneous ultrasound: Consider for patients who struggle to swallow contrast or those with a palpable neck mass. ^[6]

Barium swallow with videofluoroscopy is the first-line test for diagnosing esophageal diverticula, and it may also show any associated aspiration and/or regurgitation. ^[7]

Endoscopy ^[2]

• Indications: all patients with middle or lower esophageal diverticula ^[1]
• Findings
  • Esophageal cancer (which may be hidden in the pouch)
  • Esophagitis, Barrett esophagus

Esophageal manometry ^[2]

• Indications: all patients with middle or lower esophageal diverticula, even if asymptomatic
• Findings: evidence of an underlying motility disorder

Surgical treatment is indicated for patients with symptomatic esophageal diverticula and can be considered for asymptomatic diverticula ≥ 2 cm. ^[2]

Zenker diverticulum ^[8]

• Approaches
  • Open surgery: suitable for all patients who can tolerate general anesthesia
  • Flexible endoscopy: Consider for medium-sized diverticula (e.g., 2–5 cm). ^[2]
  • Rigid endoscopy: may not be possible in older patients with restricted neck mobility
• Procedures: based on diverticulum size and the chosen approach (i.e., endoscopy or open surgery)
  • Cricopharyngeal myotomy: incision of the cricopharyngeal muscle (the main component of the upper esophageal sphincter) to relieve esophageal obstruction; indicated for most patients ^[2]
  • Diverticulotomy: division of the septum that separates a diverticulum from the physiological esophageal lumen
  • Diverticulectomy: resection of a diverticulum ^[2]
  • Diverticulopexy: suspension of a diverticulum onto the hypopharyngeal wall
  • Diverticular inversion
  • Other options include stapling, electrocautery, or CO₂ laser treatment.
• Goal: to reduce pressure in the upper esophageal sphincter by removing or isolating the diverticulum

Other diverticula ^[2]

• Symptomatic or diverticulum ≥ 2 cm: Consider surgical intervention (e.g., diverticulopexy).
• Asymptomatic
  • Treat any presumed underlying cause (e.g., esophageal motility disorders).
  • Employ expectant management.

Middle and distal esophageal diverticula are usually small and asymptomatic. Focus treatment on associated underlying conditions. ^[2]

• Aspiration pneumonia ^[6]
• Perforation with mediastinitis and fistula formation (rare)
• Esophageal cancer ^[9]

We list the most important complications. The selection is not exhaustive.