Updated: 10/9/2019

Zenker Diverticulum

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Snapshot
  • A 59-year-old man presents to the clinic for complaints of bad breath and recurrent coughing spells. He complains difficulty swallowing at times and is noted to have a moderately sized neck mass during physical examination.
Introduction
  • False diverticulum (sac-like outpouching of only the mucosa and submucosa) of the esophagus 
    • true diverticulum contains all layers of the intestinal wall
  • Epidemiology
    • incidence
      • prevalence of 0.01 - 0.11% in the U.S.A.
    • demographics
      • 1.5:1 male predominance
      • typically seen in middle-aged adults and older adults in 7-8th decade of life
    • location
      • occurs at the upper part of the esophagus at Killian triangle (an area of muscular weakness between the cricopharyngeus muscle and lower inferior constriction)   
  • Pathogenesis
    • Killian triangle is a natural area of weakness within the muscular wall of the esophagus and is more common in men
    • thought to result from chronic increased pressure on the weakened area due to either
      • high intrabolus pressures during swallowing
      • resistance to swallowing due to abnormalities of the upper esophageal sphincter
  • Prognosis
    • ranges widely depending on health of patient and surgical approach
    • disease itself is rarely life-threatening
Presentation
  • Symptoms
    • dysphagia
    • regurgitation
    • choking
    • halitosis (bad breath)
    • chronic cough
  • Physical exam
    • palpable, fluctuant neck mass
Imaging 
  • Barium swallow 
    • preferred method of diagnosis  
    • will demonstrate dye collection posterior to the esophagus
  • Transcutaneous ultrasound
    • allows for differentiation from a thyroid/neck mass
    • good alternative for people who have difficulties swallowing barium
  • Esophageal manometry
    • not required for diagnosis
    • may help delineating the pathogenesis of the diverticulum
Differential
  • Achalasia
    • distinguishing factor
      • will demonstrate a bird’s beak on barium swallow
  • Diffuse esophageal spasm
    • distinguishing factor
      • will have characteristic findings on esophageal manometry
Treatment
  • Conservative treatment
    • if diverticulum is small and asymptomatic, no treatment is necessary
  • Operative
    • myotomy of cricopharyngeus muscle with diverticulum resection
      • indication
        • if the diverticulum is large and symptomatic
        • endoscopic approach has better success rates compared to external approach

Complications

  • Aspiration pneumonia
  • Squamous cell carcinoma of the diverticulum
    • prevalence ranges from 0.3-7 %
  • Ulceration and bleeding
  • Increased risk of iatrogenic perforation
 

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Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M1.GI.75) A 73-year-old man presents with complaints of long standing halitosis. He has recently been having progressive difficulty with swallowing. In the last several weeks, he has also noticed a small amount of regurgitated food on his pillow in the morning. You obtain the radiographic study depicted in Figure A. What is the most likely diagnosis?
Review Topic

QID: 106813
FIGURES:
1

Achalasia

5%

(7/141)

2

Zenker's diverticulum

92%

(130/141)

3

Squamous esophageal carcinoma

1%

(1/141)

4

Esophageal adenocarcinoma

1%

(1/141)

5

Diffuse esophageal spasm

0%

(0/141)

M1

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SUBMIT RESPONSE 2

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(M1.GI.57) A 72-year-old Caucasian male presents to your office with dysphagia and halitosis. If this patient is also found to have cricopharyngeal muscle dysfunction, which of the following is the most likely cause of his presenting symptoms? Review Topic

QID: 101114
1

Gastroesophageal reflux disease

2%

(5/264)

2

Esophageal candidiasis

3%

(7/264)

3

Glossopharyngeal nerve damage

12%

(32/264)

4

Meckel's diverticulum

2%

(6/264)

5

Zenker's diverticulum

80%

(211/264)

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