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Updated: Jun 6 2020

Zenker Diverticulum

  • 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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