Updated: 6/6/2020

Zenker Diverticulum

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Topic
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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Questions (3)
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(M1.GI.15.75) 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?
Tested Concept

QID: 106813
FIGURES:
1

Achalasia

5%

(7/153)

2

Zenker's diverticulum

92%

(141/153)

3

Squamous esophageal carcinoma

1%

(1/153)

4

Esophageal adenocarcinoma

1%

(1/153)

5

Diffuse esophageal spasm

1%

(1/153)

M 1 E

Select Answer to see Preferred Response

(M1.GI.13.57) 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? Tested Concept

QID: 101114
1

Gastroesophageal reflux disease

2%

(5/274)

2

Esophageal candidiasis

3%

(8/274)

3

Glossopharyngeal nerve damage

12%

(32/274)

4

Meckel's diverticulum

2%

(6/274)

5

Zenker's diverticulum

80%

(219/274)

M 2 E

Select Answer to see Preferred Response

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VIDEOS (1)
Topic COMMENTS (2)
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