Diverticulum - Disorders of the Esophagus

DIVERTICULUM

A diverticulum is an outpouching of mucosa and submucosa that protrudes through a weak portion of the musculature. Divertic-ula may occur in one of the three areas of the esophagus—the pharyngoesophageal or upper area of the esophagus, the mides-ophageal area, or the epiphrenic or lower area of the esophagus— or they may occur along the border of the esophagus intramurally.

The most common type of diverticulum, which is found three times more frequently in men than in women, is Zenker’s diverticulum (also known as pharyngoesophageal pulsion diver-ticulum or a pharyngeal pouch). It occurs posteriorly through the cricopharyngeal muscle in the midline of the neck. It is usu-ally seen in people older than 60 years of age. Other types of di-verticula include midesophageal, epiphrenic, and intramural diverticula.

Midesophageal diverticula are uncommon. Symptoms are less acute, and usually the condition does not require surgery. Epiphrenic diverticula are usually larger diverticula in the lower esophagus just above the diaphragm. They are thought to be re-lated to the improper functioning of the lower esophageal sphinc-ter or to motor disorders of the esophagus. Intramural diverticulosis is the occurrence of numerous small diverticula associated with a stricture in the upper esophagus.

Clinical Manifestations

Symptoms experienced by the patient with a pharyngoesophageal pulsion diverticulum include difficulty swallowing, fullness in the neck, belching, regurgitation of undigested food, and gurgling noises after eating. 

The diverticulum, or pouch, becomes filled with food or liquid. When the patient assumes a recumbent po-sition, undigested food is regurgitated, and coughing may be caused by irritation of the trachea. Halitosis and a sour taste in the mouth are also common because of the decomposition of food retained in the diverticulum.

Symptoms produced by midesophageal diverticula are less acute. One third of patients with epiphrenic diverticula are asymptomatic, and the remaining two thirds complain of dysphagia and chest pain. Dysphagia is the most common complaint of patients with intramural diverticulosis.

Assessment and Diagnostic Findings

A barium swallow may be performed to determine the exact na-ture and location of a diverticulum. Manometric studies are often performed for patients with epiphrenic diverticula to rule out a motor disorder. Esophagoscopy usually is contraindicated be-cause of the danger of perforation of the diverticulum, with re-sulting mediastinitis (inflammation of the organs and tissues that separate the lungs). Blind insertion of a nasogastric tube should be avoided.

Management

Because pharyngoesophageal pulsion diverticulum is progressive, the only means of cure is surgical removal of the diverticulum. During surgery, care is taken to avoid trauma to the common carotid artery and internal jugular veins. The sac is dissected free and amputated flush with the esophageal wall. In addition to a diverticulectomy, a myotomy of the cricopharyngeal muscle is often performed to relieve spasticity of the musculature, which otherwise seems to contribute to a continuation of the previous symptoms. Postoperatively, the patient may have a nasogastric tube inserted at the time of surgery. The surgical incision must be observed for evidence of leakage from the esophagus and a de-veloping fistula. Food and fluids are withheld until x-ray studies show no leakage at the surgical site. The diet begins with liquids and progresses as tolerated.

Surgery is indicated for epiphrenic and midesophageal diver-ticula only if the symptoms are troublesome and becoming worse. Treatment consists of a diverticulectomy and long myotomy. In-tramural diverticula usually regress after the esophageal stricture is dilated.