Esophageal Diverticula Clinical Presentation

Updated: Dec 24, 2020
  • Author: Jack Bragg, DO; Chief Editor: Praveen K Roy, MD, AGAF  more...
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Zenker diverticulum

A Zenker diverticulum, which is seen in the images below, is formed by the herniation of mucosa through an area of weakness in the posterior wall of the hypopharynx (the Killian triangle).

Esophageal Diverticula. Barium esophagram, anterop Esophageal Diverticula. Barium esophagram, anteroposterior view, demonstrating a bilobed Zenker diverticulum.
Esophageal Diverticula. Zenker diverticulum, later Esophageal Diverticula. Zenker diverticulum, lateral view.

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.

Killian-Jamieson diverticula originate in the anterolateral wall just below the cricopharyngeus (Killian-Jamieson space). [4]

Oropharyngeal dysphagia, usually to solids and to liquids, is the most common symptom. [1] 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.

There have been several reports in the literature regarding difficulty in distinguishing cervical esophageal cancer or Zenker or Killian-Jamieson diverticula from thyroid nodules. [5, 6, 7] The authors recommend carefull evaluation of the lesion with ultrasound, fine needle aspiration if necessary, and endoscopy.

Esophageal diverticula

Diverticula of the esophageal body are relatively rare. They primarily occur in the middle and distal esophagus (see the image below).

Esophageal Diverticula. Esophagram demonstrating a Esophageal Diverticula. Esophagram demonstrating a dilated tortuous esophagus and a large midesophageal diverticulum.

Diverticula that occur in the distal esophagus, in the lower 6-10 cm, are termed epiphrenic diverticula (see the image below).

Esophageal Diverticula. Barium esophagram demonstr Esophageal Diverticula. Barium esophagram demonstrating an epiphrenic diverticulum.

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

Esophageal intramural pseudodiverticulosis, which is seen in the images below, is a very rare condition in which numerous 1- to 4-mm, saccular, flask-shaped outpouchings form in the wall of the esophagus. 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.

Esophageal Diverticula. Multiple, small, flask-sha Esophageal Diverticula. Multiple, small, flask-shaped outpouchings characteristic of esophageal intramural pseudodiverticulosis.
Esophageal Diverticula. Esophageal intramural pseu Esophageal Diverticula. Esophageal intramural pseudodiverticulosis involving the entire length of the esophagus.

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 cited significant bleeding from a distal esophageal diverticulum. The authors speculated that the bleeding resulted from food stasis, bacterial overgrowth, or chronic inflammation.

Halm and colleagues reported a series of 23 patients with esophageal intramural pseudodiverticulosis diagnosed endoscopically and their therapy. [8] In a retrospective study of the endoscopic criteria of intramural pseudodiverticulitis, associated diseases and clinical course, they determined that alcohol consumption and tobacco use were present in all patients. About half had a proximal esophageal stenosis that was relieved with bougienage. Rarely, it has been reported in patients with human immunodeficiency virus (HIV) infection. [8]


Physical Examination

Findings on physical examination often are normal in patients with symptomatic esophageal diverticula. However, many patients relate a history of dysphagia, chest pain, or regurgitation.

Although the physical examination findings are often normal, a large Zenker diverticulum may present as a neck mass on physical examination. Halitosis also may be present and is secondary to accumulated food debris or medicines within the diverticulum.

Signs and symptoms of aspiration pneumonia may accompany the presence of large symptomatic diverticula.