Esophageal Diverticula

Last Updated: November 16, 2006 Email to a Colleague

Synonyms and related keywords: esophageal diverticulum, Zenker diverticulum,

Zenker's diverticulum, pharyngoesophageal diverticula, hypopharynx, congenital
esophageal diverticulum, acquired esophageal diverticulum, diverticulum of the
esophageal body, true esophageal diverticula, false esophageal diverticula,
pseudodiverticula of the esophagus, esophageal intramural pseudodiverticulosis,
pulsion diverticula of the esophagus, traction diverticula of the esophagus,
dysphagia, epiphrenic diverticula, regurgitation, nocturnal cough, aspiration
pneumonia, Ehlers-Danlos syndrome

AUTHOR INFORMATION Section 1 of 11

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Author: Jack Bragg, DO, FACOI, Assistant Professor, Department of Clinical

Medicine, University of Missouri School of Medicine
Coauthor(s): Christopher (Kit) Bartalos D.O., Fellow, Department of
Gastroenterology, University of Missouri, Columbia Missouri; Rodney A Perez,
MD, Medical Director, The Endoscopy Center, Asheville Gastroenterology
Associates; Consulting Staff, Department of Gastroenterology, Mission St
Joseph's Hospital; John B Marshall, MD, Professor, Department of Internal
Medicine, Division of Gastroenterology, University of Missouri School of Medicine

Jack Bragg, DO, FACOI, is a member of the following medical societies:

American College of Osteopathic Internists, and American Osteopathic
Association

Editor(s): Maurice A Cerulli, MD, FACG, Chief, Division of Gastroenterology and

Hepatology, Associate Professor of Clinical Medicine, Department of Internal
Medicine, Division of Gastroenterology, New York Methodist Hospital, Cornell
University; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor,
eMedicine; Simmy Bank, MD, Chair, Professor, Department of Internal Medicine,
Division of Gastroenterology, Long Island Jewish Hospital, Albert Einstein
College of Medicine; Alex J Mechaber, MD, FACP, Assistant Dean for Medical
Curriculum, Associate Professor of Medicine, Division of General Internal
Medicine, University of Miami Miller School of Medicine; and Julian Katz, MD,
Clinical Professor of Medicine, Drexel University College of Medicine; Consulting
Staff, Department of Medicine, Section of Gastroenterology and Hepatology,
Hospital of the Medical College of Pennsylvania

Disclosure

INTRODUCTION Section 2 of 11
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Background: A diverticulum is a sac or pouch arising from a tubular organ, such

as the esophagus. This article focuses on diverticula of the esophagus. As is
common practice, Zenker diverticulum, a type of diverticulum that arises from the
posterior hypopharynx, is also discussed in this article.

Pathophysiology: Besides anatomical location, several other ways to classify

diverticula of the esophagus and hypopharynx exist. Congenital diverticula are
diverticula that are present at birth, while acquired diverticula develop later in life.
Diverticula of the esophageal body can sometimes be difficult to classify as
congenital or acquired.

Diverticula also may be classified on the basis of histopathology. True diverticula

contain all layers of the intestinal tract wall. False diverticula, also known as
pseudodiverticula, occur when herniation of mucosa and submucosa through a
defect in the muscular wall occurs (eg, Zenker diverticulum). A special type of
pseudodiverticula, believed to represent dilated excretory ducts of esophageal
submucosal glands, is observed in the condition esophageal intramural
pseudodiverticulosis.

Finally, acquired diverticula of the esophagus and hypopharynx also may be

classified according to their pathogenesis as pulsion diverticula or traction
diverticula. Pulsion diverticula form as a result of high intraluminal pressures
against weaknesses in the GI tract wall. Zenker diverticulum occurs due to
increased pressure in the oropharynx during swallowing against a closed upper
esophageal sphincter. An epiphrenic diverticulum occurs from increased pressure
during esophageal propulsive contractions against a closed lower esophageal
sphincter. In contrast, traction diverticula occur as a consequence of pulling
forces on the outside of the esophagus from an adjacent inflammatory process
(eg, involvement of inflamed mediastinal lymph nodes in tuberculosis or
histoplasmosis).
Age: Most esophageal diverticula occur in middle-aged adults and elderly people,
although presentation in infants and children is rarely seen. Zenker diverticula
typically present in people older than 50 years and especially present during the
seventh and eighth decades of life.

CLINICAL Section 3 of 11
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History:

Zenker diverticula (see Images 1-2) are formed by the herniation of mucosa
through an area of weakness in the posterior wall of the hypopharynx (the Killian
triangle).
Sometimes Zenker diverticula are called pharyngoesophageal diverticula
because of their close proximity to the cervical esophagus; however, this is
somewhat of a misnomer because the diverticula actually arise from the
hypopharynx rather than from the esophagus.
Of the diverticula discussed in this article, Zenker diverticula are the most
common type to cause symptoms.
Zenker diverticula are an acquired pulsion-type of diverticula that probably
develop because of the aging process. They form in the posterior hypopharynx at
a point where a defect in the muscular wall, between the inferior pharyngeal
constrictor muscle and the cricopharyngeal sphincter (Killian triangle), usually
exists.
Zenker diverticula are believed to occur because of an outflow obstruction
caused when loss of coordination of the buccal squirt (ie, swallowing movement
of the tongue posteriorly with contraction of the oropharyngeal muscles) and
opening of the cricopharyngeus (ie, the upper esophageal sphincter) occurs. The
noncompliant cricopharyngeus muscle becomes fibrotic over time.
Zenker diverticula typically present in people older than 50 years and especially
present during the seventh and eighth decades of life.
Oropharyngeal dysphagia, usually to solids and to liquids, is the most common
symptom. Retention of food material and secretions in the diverticulum,
particularly when diverticula are large, can result in regurgitation of undigested
food, halitosis, cough, and even aspiration pneumonia. The patient may note
food on the pillow upon awakening in the morning. With very large diverticula, a
mass in the neck occasionally can be detected. Cancer rarely has been reported
in association with Zenker diverticula.
Diverticula of the esophageal body are relatively rare. They primarily occur in
the middle and distal esophagus (see Image 3).
Diverticula that occur in the distal esophagus, in the lower 6-10 cm, are termed
epiphrenic diverticula (see Image 4).
Diverticula of the mid and distal esophagus may have various etiologies. For
instance, some diverticula in the mid esophagus are congenital in origin; others
are of the traction variety. With the latter, diverticula develop by traction from
contiguous mediastinal inflammation and adenopathy, eg, pulmonary
tuberculosis and histoplasmosis. The diverticula that develop by traction and
adenopathy usually are asymptomatic.
Retention of undigested food in large diverticula occasionally results in
regurgitation, nocturnal cough, and aspiration pneumonia.
Occasional epiphrenic diverticula occur in the setting of long-standing peptic
esophagitis and strictures, and they rarely are symptomatic. Other rare causes of
diverticula of the mid and distal esophagus include iatrogenic surgical injury to
the esophagus and Ehlers-Danlos syndrome (weakness of collagen). Perhaps
the most common causes of mid esophageal and epiphrenic diverticula are
motility disorders of the esophageal body, including achalasia, diffuse
esophageal spasm, and hypertensive lower esophageal sphincter.
Dysphagia is the most common symptom associated with mid esophageal and
epiphrenic diverticula, although it usually is related more to the underlying motility
disturbance than to the diverticulum per se. However, on occasion, the
diverticulum may be responsible for the dysphagia, particularly if it is very large
and filled with food or a bezoar. Regurgitation and aspiration may be related to
large mid esophageal and epiphrenic diverticula; however, in patients with
achalasia, regurgitation and aspiration are more likely to be related to poor
esophageal emptying from the underlying motility disturbance (eg, hypertensive
lower esophageal sphincter that fails to relax, absence of esophageal body
peristalsis).
Esophageal intramural pseudodiverticulosis is a very rare condition in which
numerous 1- to 4-mm, saccular, flask-shaped outpouchings form in the wall of
the esophagus (see Images 5-6). Pseudodiverticula can number from a few to a
hundred or more. This condition can be segmental or diffuse. About 200 cases
have been reported in the literature.
Pseudodiverticula are formed by dilatation of the esophageal submucosal glands
that communicate with the esophageal lumen.
Esophageal intraluminal pseudodiverticulosis generally is believed to be an
acquired condition. While the precise pathogenesis is uncertain, inflammation
and stasis appear to be factors. One hypothesis states that blockage of
intramural ducts by inflammatory debris results in dilation of the submucosal
glands.
Most patients with esophageal intraluminal pseudodiverticulosis have underlying
esophageal strictures or dysmotility of the esophageal body. Esophageal
intraluminal pseudodiverticulosis also has been reported as a consequence of
corrosive injury to the esophagus, although most patients have associated
strictures.
Dysphagia is the most common symptom associated with esophageal intramural
pseudodiverticulosis. In most cases, esophageal intraluminal
pseudodiverticulosis is related to the associated esophageal stricture or
dysmotility.
An isolated case report recently cited significant bleeding from a distal
esophageal diverticulum. The authors speculate the bleeding resulted from food
stasis, bacterial overgrowth, or chronic inflammation.
Physical:

Findings on physical examination often are normal in patients with symptomatic

esophageal diverticula. However, many patients relate a history of dysphagia,
chest pain, or regurgitation.
Although the physical examination findings are often normal, a large Zenker
diverticulum may present as a neck mass on physical examination. Halitosis also
may be present and is secondary to accumulated food debris or medicines within
the diverticulum.
Signs and symptoms of aspiration pneumonia may accompany the presence of
large symptomatic diverticula.
Causes:

Most diverticula are caused by an underlying motility disorder of the esophagus.

Structural lesions, including a noncompliant cricopharyngeus muscle (ie, Zenker
diverticulum), incomplete or uncoordinated relaxation of the lower esophageal
sphincter, or strictures, may play a role as well.
An underlying inflammatory process within the mediastinum has been associated
with mid esophageal diverticula.
DIFFERENTIALS Section 4 of 11
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Achalasia
Esophageal Cancer
Esophageal Motility Disorders
Esophageal Spasm
Esophageal Stricture
Gastroesophageal Reflux Disease
Zenker Diverticulum

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Related Articles
Achalasia

Esophageal Cancer

Esophageal Motility Disorders

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Gastroesophageal Reflux Disease

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Diverticulosis and Diverticulitis Overview

Diverticulosis and Diverticulitis Causes

Diverticulosis and Diverticulitis Symptoms

Diverticulosis and Diverticulitis Treatment

 WORKUP Section 5 of 11
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Lab Studies:

Most laboratory studies are not helpful in the diagnosis. (Upper esophageal webs
have been associated with iron deficiency anemia.)
Imaging Studies:

Radiographic studies or upper GI endoscopy detects many esophageal

diverticula incidentally because esophageal diverticula often are asymptomatic.
On standard chest radiographs and CT scans, large diverticula of the
esophagus and hypopharynx also may manifest as air-filled and/or fluid-filled
structures communicating with the esophagus.
Barium radiography (ie, barium esophagography, barium swallow) generally is
the diagnostic procedure of choice. In addition to being excellent at defining the
structural appearance of diverticula, barium swallow also may provide clues to
underlying motility disturbances that may be involved in diverticular formation.
However, if the patient has dysphagia or odynophagia or has alarm symptoms,
then upper endoscopy is indicated.
Barium swallow is a useful study in patients who are symptomatic and have mid
esophageal and epiphrenic diverticula.
Diagnosis of esophageal intramural pseudodiverticulosis is made best using
barium radiography.
Diagnosis of Zenker diverticulum is made best using barium swallow, which
should include lateral views of the pharyngoesophageal junction. It also can be
made using careful upper endoscopy by an experienced endoscopist.
Other Tests:

Esophageal manometry can be helpful to evaluate lower esophageal sphincter

pressure, lower esophageal sphincter relaxation, and esophageal body function
in symptomatic patients if achalasia or another esophageal motility disorder is
suspected or if surgery is being considered. It can also demonstrate the
incoordination between the buccal squirt and relaxation of the cricopharyngeus,
although special manometric techniques are usually required. In patients with
dysphagia, esophageal manometry is helpful to better define underlying motility
disorders.
Procedures:

Perform esophagogastroduodenoscopy to rule out structural conditions of the

esophagus, such as strictures or neoplasms, that have been associated with
esophageal diverticula.
Flexible endoscopy is a useful study in patients who are symptomatic and have
mid esophageal and epiphrenic diverticula.
Endoscopy is unnecessary in a patient with Zenker diverticula if the diagnosis
has been made using barium radiograph. If flexible upper GI endoscopy is
needed in a patient with a known Zenker diverticulum, it should be performed
with caution, with the endoscope being passed under direct visualization to
minimize the risk of perforation.
TREATMENT Section 6 of 11
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Medical Care:

Asymptomatic and minimally symptomatic esophageal body diverticula do not

require treatment.
In many patients with mid esophageal and epiphrenic diverticula, dysphagia is
related to underlying dysmotility; thus, treatment should be directed to the motility
disorder when feasible. For instance, achalasia can be treated with pneumatic
dilation, botulinum toxin injection into the lower esophageal sphincter, or surgical
Heller esophagomyotomy.
Treatment of esophageal intramural pseudodiverticulosis is directed toward
underlying strictures or dysmotility.
Surgical Care: Treatment of Zenker diverticulum traditionally has been surgical,
although the specific operation used still is controversial. Surgical options include
diverticulectomy with cricopharyngeal myotomy, diverticular suspension
(diverticulopexy) with cricopharyngeal myotomy, and cricopharyngeal myotomy
alone.

Consider diverticulectomy when esophageal body diverticula are believed to be

the cause of aspiration. An abdominal laparoscopic approach may be feasible for
some patients with epiphrenic diverticula. Case reports of endoscopic treatment
of giant midesophageal diverticula have recently been reported. However,
patients who are being considered for diverticulectomy should first undergo
careful study with barium swallow, flexible endoscopy, and esophageal
manometry. Treatment directed at an underlying esophageal motility disorder,
such as achalasia, cannot be ignored.
Diverticulectomy usually is not performed by itself because it does not correct the
defect in cricopharyngeal function that usually contributes to the formation of a
Zenker diverticulum.
While the transcervical approach has been used traditionally, the transoral route
using a rigid esophagoscope also may be used.
Recently, good results have been obtained by performing a diverticulotomy using
a flexible endoscope and needle-knife papillotome to cut the common wall
between the diverticulum and the oropharynx as well as the cricopharyngeus
while the patient is consciously sedated. In some variations of this technique, the
diverticulum is stapled.
Within the last few years, increased efforts to a laparoscopic approach to repair
both epiphrenic diverticula and Zenker diverticula have been explored. The
literature supports both open surgery and a laparoscopic approach as
appropriate methods of repair. The laparoscopic technique uses stapler closure,
and multiple case reports cite wound leakage from stapler failure as a
complication. With complication rates as high as 20%, a skilled surgeon with
experience in this procedure is beneficial. Benefits of the laparoscopic approach
include decreased morbidity because of no thoracotomy wounds and chest tubes
and a less invasive approach.
Consultations:

Gastroenterologist - For patients who have symptoms associated with

esophageal diverticula or who have esophageal motility disorders, such as
achalasia.
General or thoracic surgeon (with experience) after gastroenterological
evaluation - For patients who have significant symptoms associated with Zenker
diverticulum, achalasia, or diverticula.

MEDICATION Section 7 of 11
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Botulinum toxin has been used successfully as an alternative to surgical

myotomy or pneumatic dilation for the treatment of achalasia.

Drug Category: Neuromuscular blocker agents -- May relax smooth muscle.Drug

Name
Botulinum toxin A (BOTOX) -- Botulinum toxin type A is produced by
Clostridium botulinum and is responsible for botulism in humans. Botulinum toxin
type A produces denervation of affected muscle tissue by irreversibly binding to
presynaptic nerve endings and inhibiting the release of acetylcholine.
When endoscopically injected into the lower esophageal sphincter (LES),
interference with cholinergic transmission of the myenteric plexus leads to
smooth muscle relaxation with a subsequent fall of the LES resting pressure.
This drug has been used in other fields of medicine to treat spastic torticollis and
blepharospasm.
Adult Dose 80 U injected into squamocolumnar junction under direct endoscopic
visualization; 5-mm injector or sclerotherapy needle used to infiltrate 20 U in 4
quadrants
Pediatric Dose <12 years: Not established
>12 years: Administer as in adults
Contraindications Documented hypersensitivity
Interactions Aminoglycosides or drugs that interfere with neuromuscular
transmission may potentiate effects of botulinum toxin
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions May cause diffuse skin rash, chest pain, or heartburn; do not exceed
recommended dosages and frequencies of administration; presence of
antibodies to botulinum toxin type A may reduce effects of therapy
FOLLOW-UP Section 8 of 11
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Complications:

Recurrent aspiration pneumonia has been associated with large symptomatic

esophageal diverticula and Zenker diverticula.
Rarely, carcinoma has been reported to develop within a diverticulum.
Patient Education:

For excellent patient education resources, visit eMedicine's Esophagus,

Stomach, and Intestine Center. Also, see eMedicine's patient education article
Diverticulosis and Diverticulitis.
MISCELLANEOUS Section 9 of 11
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Medical/Legal Pitfalls:
Diverticula of the esophagus may be associated with motility disorders or
structural disorders of the esophagus, such as strictures. In a patient with a
known esophageal diverticulum, only experienced endoscopists should perform
esophageal dilation for strictures. Esophageal dilation can be performed safely
by several different means.
The use of through-the-scope dilating balloon catheters is an effective way to
dilate esophageal strictures while maintaining a full endoscopic view during
dilation.
Similarly, guide wireassisted dilation with polyvinyl dilators, with or without the
use of fluoroscopy, allows for added safety during esophageal dilation in patients
with esophageal diverticula.
Blind passage of mercury-filled rubber bougies (Maloney dilators) probably
should not be performed because of the possibility of the dilator entering the
diverticula with subsequent perforation. Similarly, nasogastric tubes or other
nasoenteric devices are best passed with the aid of either endoscopy or
fluoroscopy for the same reasons.
PICTURES Section 10 of 11
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Caption: Picture 1. Esophageal diverticula. Barium esophagram, anteroposterior

view, demonstrating a bilobed Zenker diverticulum.
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Picture Type: X-RAY

Caption: Picture 2. Esophageal diverticula. Zenker diverticulum, lateral view.
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Picture Type: X-RAY

Caption: Picture 3. Esophagram demonstrating a dilated tortuous esophagus and
a large mid esophageal diverticulum.
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Picture Type: X-RAY

Caption: Picture 4. Esophageal diverticula. Barium esophagram demonstrating
an epiphrenic diverticulum.
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Picture Type: X-RAY

Caption: Picture 5. Esophageal diverticula. Multiple, small, flask-shaped
outpouchings characteristic of esophageal intramural pseudodiverticulosis.
View Full Size Image
Picture Type: X-RAY
Caption: Picture 6. Esophageal diverticula. Esophageal intramural
pseudodiverticulosis involving the entire length of the esophagus.
View Full Size Image

Picture Type: X-RAY

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