Esophageal diverticulum 

Definition

Esophageal diverticulum is a deformity of the esophageal wall characterized by sac-like bulging of its layers facing towards the mediastinum. It can manifest in a feeling of persistence, hypersalivation, a lump in the throat, dysphagia, regurgitation, and putrid breath odor. Pathology is diagnosed with the help of esophageal radiography, esophagoscopy, and manometry. Radical treatment involves excision of the diverticulum (diverticulectomy) or invagination of the bulge into the esophageal lumen.

General information

Esophageal diverticula are detected in 2% of individuals during radiologic examination. In modern gastroenterology, they account for about 40% of gastrointestinal diverticula. They are more often diagnosed in men over 50 years old, usually suffering from other digestive system diseases – peptic ulcer disease, cholecystitis, cholelithiasis, cholelithiasis, and so on. The diverticulum can develop in any segment of the esophagus, but it is more often formed in the thoracic part. In 90% of cases, it is solitary; in 10%, there are multiple bulges of the esophageal wall.

Causes

The origin of esophageal diverticula can vary. The formation of congenital protrusion is usually associated with primary weakness of the muscular layer of the esophageal wall in a particular area. Inflammatory processes of the upper GI tract and mediastinum play a significant role in the development of acquired diverticula.

Pathology is often preceded by a long course of esophagitis and gastroesophageal reflux disease, mediastinitis, tuberculosis of intrathoracic lymph nodes, and fungal infection of the esophagus (esophageal candidemia). Esophageal trauma, spasm, cardia achalasia, and esophageal strictures can lead to esophageal diverticulum development.

Pathogenesis

The formation of a pulsatile diverticulum is caused by impaired esophageal motility leading to spastic contractions of the musculature, increased intraesophageal pressure, and bulging of the wall at the weakest point (often above a functional or organic narrowing).

The development of a traction diverticulum is facilitated by connective tissue fusion of the esophageal wall with inflamed mediastinal lymph nodes. This causes stretching and displacement of the esophageal wall towards the mediastinum, forming a pathologic bulge. Sometimes, pulsatile and traction mechanisms affect simultaneously.

Classification

According to location, there are pharyngeal-esophageal (pharyngoesophageal, Zenker’s diverticulum), epibronchial (middle esophageal, bifurcation), supradiaphragmatic (epiphrenal), and subdiaphragmatic (abdominal) esophageal diverticula. According to the mechanism of formation, the bulges may be pulsatile, tractional, or mixed—pulsatile-tractional.

Diverticula are classified into congenital and acquired diverticula according to their origin and time of onset. The type of structure distinguishes between true diverticula, which consists of all esophageal wall layers, and pseudodiverticula, which have no muscular lining. False diverticula are formed by protrusion of the esophageal mucosa through a defect in the muscular layer; they occur at the time of peristaltic contraction of the esophageal wall and disappear when it relaxes.

Symptoms of esophageal diverticulum

Clinical manifestations depend on the localization of the protrusion. The most vivid symptoms are caused by Zenker’s diverticula, located in the area of the pharyngeal-esophageal junction. In Zenker diverticula, dysphagia—the difficult passage of solid and liquid food through the esophagus—develops early. Food residues accumulate in the diverticulum, accompanied by regurgitation of undigested food and unpleasant oral odor.

Regurgitation may be observed in the supine position, and patients often find mucus and food residue on the pillow upon awakening. Patients may also complain of fever, scratching of the pharynx, a feeling of an unabsorbed lump in the throat, and a dry cough. Nausea, hypersalivation, and a change in the timbre of the voice are often noted. 

Small (up to 2 cm) bifurcation and supradiaphragmatic diverticula are usually asymptomatic. Large diverticula are accompanied by dysphagia, regurgitation of undigested food, aerophagia (swallowing air), chest pain, nausea, and night cough. Clinical manifestations of bifurcation diverticulum may be provoked by a Valsava test. In lower esophageal diverticula, reflex dyspnea, tachycardia, bronchospasm, cardiac pain, and ECG changes are added to the clinic of digestive disorders.

Complications

Esophageal diverticula may be accompanied by diverticulitis and its complications—phlegmon of the neck, mediastinitis, formation of esophageal-mediastinal fistula, and sepsis. Regurgitation with aspiration of food masses can lead to the development of chronic bronchitis, aspiration pneumonia, and lung abscess. It is possible for mucosa erosion to erode, esophageal bleeding, formation of esophageal polyps, and the development of esophageal cancer.

Diagnosis

A large Zenker’s diverticulum can be detected by examination and palpation of the neck. A soft bulge in the neck area shrinks when pressure is applied. X-ray of the esophagus establishes the presence and localization of the diverticulum, determines the width of its neck, the time of barium retention, and the presence of pathological processes (polyps, cancer, fistula). Review radiography and CT scan of the chest organs can provide important information: esophageal diverticula of large size can be seen on images as fluid- and air-filled cavities communicating with the esophagus.

Esophagoscopy allows one to examine the diverticulum cavity, detect mucosal ulceration, establish the fact of bleeding, detect tumors, and perform endoscopic biopsy. Due to the high risk of perforation, esophagoscopy is performed with great caution. Esophageal manometry—a study of esophageal motility—is performed to study the contractile function of the esophagus. Patients with coronary symptoms undergo ECG studies, Holter monitoring, and echocardiography.

A differential diagnosis of esophageal diverticulum is performed with GERD, esophageal spasm, paraesophageal hernia, esophageal strictures, cardia achalasia, esophageal cancer, mediastinal cysts, angina pectoris, and coronary artery disease. Diagnostic measures are carried out by a gastroenterologist; in the presence of symptoms of the cardiovascular system, consultation with a cardiologist is indicated.

Treatment of esophageal diverticulum

Small masses with an asymptomatic course are treated conservatively under the supervision of a gastroenterologist. Patients are recommended to follow a diet based on the principles of thermal, chemical, and mechanical sparing of the esophagus. After eating, it is advisable to carry out simple measures to better empty the esophageal diverticulum: drinking water, pushing, adopting a draining posture, and washing the cavity with a weak antiseptic solution.

Surgical treatment is performed for significant defects accompanied by severe dysphagia, pain, or complicated course (perforation, penetration, esophageal stenosis, bleeding, etc.). In these cases, the diverticulum is usually excised – diverticulectomy with esophageal repair with a diaphragmatic or pleural flap. Small bulges can be eliminated by invagination – immersion of the diverticulum into the esophageal lumen and suturing of the esophageal wall.

All these treatment options are available in more than 190 hospitals worldwide (https://doctor.global/results/diseases/esophageal-diverticulum). For example, Video-assisted thoracic surgery (VATS) can be done in 18 clinics across Turkey for an approximate price of $11.6 K (https://doctor.global/results/asia/turkey/all-cities/all-specializations/procedures/video-assisted-thoracic-surgery-vats). 

Prognosis and prevention

Surgical treatment ensures the complete disappearance of symptoms and good long-term results. If the course of thedisease is complicated, the prognosis is always serious. Therefore, even asymptomatic diverticula require control studies and treatment of concomitant pathology. Timely treatment of diseases that lead to their formation, as well as leisurely eating with careful chewing, facilitates the prevention of diverticula formation.