Esophageal diverticula
Esophageal diverticula: Excerpt from Handbook of Diseases
An esophageal diverticulum is an epithelial-lined mucosal pouch that protrudes from the esophageal lumen. Esophageal diverticula are classified according to their location: just above the upper esophageal sphincter (Zenker’s, or pulsion, diverticulum is the most common type), near the midpoint of the esophagus (traction diverticulum), and just above the lower esophageal sphincter (epiphrenic diverticulum).
Generally, esophageal diverticula occur later in life, although they can affect infants and children. They’re three times more common in men than in women. Zenker’s diverticula occur in patients ages 30 to 50.
Causes
Esophageal diverticula are caused by either primary muscle abnormalities that may be congenital or inflammatory processes adjacent to the esophagus.
Zenker’s diverticulum
When the pouch results from increased intraesophageal pressure, Zenker’s diverticulum occurs. It’s caused by developmental muscle weakness of the posterior pharynx above the border of the cricopharyngeal muscle. The pressure of swallowing aggravates this weakness, as does contraction of the pharynx before relaxation of the sphincter.
Traction diverticulum
When the pouch is pulled out by adjacent inflamed tissue or lymph nodes, a midesophageal (traction) diverticulum occurs. It’s a response to scarring and pulling on esophageal walls by an external inflammatory process such as tuberculosis. It’s diagnosed as an incidental finding on a barium esophagogram and is usually asymptomatic. No specific treatment is indicated.
Epiphrenic diverticulum
This diverticulum occurs within the distal 4" (10 cm) of the esophagus. It’s a pulsion diverticulum that’s caused by abnormally elevated pressure within the lumen of the esophagus.
Signs and symptoms
Traction and epiphrenic diverticula with an associated motor disturbance (achalasia or spasm) seldom produce symptoms but may cause dysphagia, heartburn, and regurgitation from associated esophageal conditions, such as hiatal hernia, diffuse esophageal spasm, achalasia, reflux esophagitis, and cancer. Zenker’s diverticulum produces distinctly staged symptoms: initially, throat irritation and, later, dysphagia and near-complete obstruction.
In early stages, regurgitation occurs soon after eating; in later stages, regurgitation after eating is delayed and may even occur during sleep, leading to food aspiration and pulmonary infection. Other symptoms include noise when liquids are swallowed, chronic cough, hoarseness, a bad taste in the mouth, and halitosis.
Diagnosis
A barium esophagogram usually confirms the diagnosis by showing characteristic outpouching. Esophagoscopy isn’t performed because the scope may be passed into the diverticulum and can cause a rupture.
Treatment
Treatment depends on the type of diverticulum. For example:
❑ A small, asymptomatic Zenker’s diverticulum may be observed. Treatment includes a bland diet, thorough chewing, and drinking water after eating to flush out the sac. Symptomatic patients may require surgery to remove the sac or to facilitate drainage. An esophagomyotomy to prevent recurrence is required in most cases.
❑ A midesophageal (traction) diverticulum seldom requires therapy except when esophagitis aggravates the risk of rupture. Then, treatment includes antacids and an antireflux regimen: keeping the head elevated, maintaining an upright position for 2 hours after eating, eating small meals, controlling chronic coughing, and avoiding constrictive clothing.
❑ Epiphrenic diverticulum requires treatment of accompanying motor disorders, such as achalasia, by repeated dilatations of the esophagus, of acute spasm by anticholinergic administration and diverticulum excision, and of dysphagia or severe pain by surgical excision; if there’s an associated hiatal hernia or incompetent lower esoph-ageal sphincter, an antireflux operation is performed. Calcium channel blockers may be used to relax smooth muscles, decrease esophageal pressure, and improve swallowing.
❑ Depending on the patient’s nutritional status, treatment may also include insertion of a nasogastric tube (passed carefully to prevent perforation) and tube feedings to prepare for the stress of surgery.
Special considerations
❑ Carefully observe and document symptoms.
❑ Assess nutritional status (weight, caloric intake, and appearance).
❑ If the patient has dysphagia, record well-tolerated foods and what circumstances ease swallowing. Provide a pureed diet with vitamin or protein supplements, and encourage thorough chewing.
❑ If the patient regurgitates food and mucus, protect against aspiration by elevating the patient’s head in high Fowler’s position.
CLINICAL TIP: To prevent aspiration, tell the patient to empty any visible outpouching in the neck by massage or postural drainage before retiring.
❑ Teach the patient about this disorder. Explain the proposed treatment and diagnostic procedures.
Book Source Details
- Book Title: Handbook of Diseases
- Author(s): Springhouse
- Year of Publication: 2003
- Copyright Details: Handbook of Diseases, Copyright © 2003 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Handbook of Diseases
Authors: Springhouse
Publisher: Lippincott Williams & Wilkins
Copyright: 2003
ISBN: 1-58255-266-5
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