An esophageal diverticulum is an epithelial-lined mucosal pouch that protrudes from the esophageal lumen. Esophageal diverticula are classified according to their location: just above the upper esophageal sphincter (Zenker's, or pulsion, diverticulum the most common type), near the midpoint of the esophagus (traction diverticulum), and just above the lower esophageal sphincter (epiphrenic diverticulum).
Generally, esophageal diverticula occur later in life, although they can affect infants and children. They are three times more common in men than in women. Zenker's diverticula occur in patients ages 30 to 50.
Esophageal diverticula are due either to primary muscle abnormalities that may be congenital or to inflammatory processes adjacent to the esophagus.
When the pouch results from increased intraesophageal pressure, Zenker's diverticulum occurs. It is caused by developmental muscle weakness of the posterior pharynx above the border of the cricopharyngeal muscle. The pressure of swallowing aggravates this weakness, as does contraction of the pharynx before relaxation ofthe sphincter.
When the pouch is pulled out by adjacent inflamed tissue or lymph nodes, a midesophageal (traction) diverticulum occurs. It's a response to scarring and pulling on esophageal walls by an external inflammatory process such as tuberculosis. It is diagnosed as an incidental finding on a barium esophagogram and is usually asymptomatic. No specific treatment is indicated.
This diverticulum occurs within the distal 10 cm of the esophagus. It is a pulsion diverticulum that is caused by abnormally elevated pressure within the lumen of the esophagus.
Signs and symptoms
Traction and epiphrenic diverticula with an associated motor disturbance (achalasia or spasm) seldom produce symptoms but may cause dysphagia, heartburn, and regurgitation from associated esophageal conditions, such as hiatal hernia, diffuse esophageal spasm, achalasia, reflux esophagitis, and cancer. Zenker's diverticulum produces distinctly staged symptoms: initially, throat irritation and, later, dysphagia and near-complete obstruction.In early stages, regurgitation occurs soon after eating; in later stages, regurgitation after eating is delayed and may even occur during sleep, leading to food aspiration and pulmonary infection. Other symptoms include noise when liquids are swallowed, chronic cough, hoarseness, a bad taste in the mouth, and halitosis.
A barium esophagogram usually confirms the diagnosis by showing characteristic outpouching. Esophagoscopy is not performed because the scope may be passed into the diverticulum and can cause a rupture.
Treatment for this condition is primarily aimed at alleviating symptoms. Physicians direct the patient to eat a bland diet, to chew his or her food thoroughly, and to drink water after eating to clean out the pouches. If the condition is severe, several types of surgery are available to remove the pouches and repair the defects. If a pouch is due to a stenosis (narrowing) in the esophagus it may be possible to relieve it by passing a dilator through it, a process called bougeinage.
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