Esophageal diverticula
Esophageal diverticula: Excerpt from Professional Guide to Diseases (Eighth Edition)
Esophageal diverticula are hollow outpouchings of one or more layers of the esophageal wall. They occur in three main areas: just above the upper esophageal sphincter (Zenker’s, or pulsion, diverticulum, the most common type); near the midpoint of the esophagus (traction); and just above the lower esophageal sphincter (epiphrenic). Generally, esophageal diverticula occur later in life — although they can affect infants and children — and are three times more common in men than in women. Epiphrenic diverticula usually occur in middle-aged men, whereas Zenker’s diverticula typically affect men older than age 60.
Causes and incidence
Esophageal diverticula are due to primary muscular abnormalities that may be congenital or to inflammatory processes adjacent to the esophagus. Zenker’s diverticulum occurs when the pouch results from increased intraesophageal pressure; traction diverticulum occurs when the pouch is pulled out by adjacent inflamed tissue or lymph nodes. Some authorities classify all diverticula as traction diverticula.
Zenker’s diverticulum results from developmental muscular 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. A midesophageal (traction) diverticulum is a response to scarring and pulling on esophageal walls by an external inflammatory process such as tuberculosis. An epiphrenic diverticulum (rare) is generally right-sided and usually accompanies an esophageal motor disturbance, such as esophageal spasm or achalasia. It’s thought to be caused by traction and pulsation.
Most diverticula occur in middle-aged and elderly patients. Zenker’s diverticula most commonly in patients older than age 50 and are especially prevalent in patients in their 70s and 80s.
Signs and symptoms
Midesophageal and epiphrenic diverticula with an associated motor disturbance (achalasia or spasm) seldom produce symptoms, although the patient may experience dysphagia and heartburn. Zenker’s diverticulum, however, produces distinctly staged symptoms, beginning with initial throat irritation followed by 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.
ELDER TIP Hoarseness, asthma, and pneumonitis may be the only signs of esophageal diverticula in elderly patients.
Other signs and symptoms include noise when liquids are swallowed, chronic cough, hoarseness, a bad taste in the mouth or foul breath and, rarely, bleeding.
Diagnosis
CONFIRMING DIAGNOSIS X-rays taken following a barium swallow usually confirm the diagnosis by showing characteristic outpouching.
Esophagoscopy can rule out another lesion; however, the procedure risks rupturing the diverticulum by passing the scope into it rather than into the lumen of the esophagus, a special danger with Zenker’s diverticulum.
Treatment
Treatment of Zenker’s diverticulum is usually palliative and includes a bland diet, thorough chewing, and drinking water after eating to flush out the sac. However, severe symptoms or a large diverticulum necessitates surgery to remove the sac or facilitate drainage. An esophagomyotomy may be necessary to prevent recurrence.
A midesophageal diverticulum seldom requires therapy except when esophagitis aggravates the risk of rupture, in which case 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. Achalasia is treated by repeated dilations of the esophagus; acute spasm is controlled by anticholinergic administration and diverticulum excision; and dysphagia or severe pain are relieved by surgical excision or suspending the diverticulum to promote drainage. Treatment may also include parenteral feeding to improve the patient’s nutritional status.
Special considerations
Care includes documenting the patient’s symptoms and nutritional status and educating him about the disorder.
❑ Regularly assess the patient’s nutritional status (weight, calorie intake, and appearance).
❑ If the patient regurgitates food and mucus, protect against aspiration by positioning him carefully (head elevated or turned to one side). To prevent aspiration, tell the patient to empty any visible outpouching in the neck by massage or postural drainage before retiring.
❑ 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.
❑ Teach the patient about this disorder. Explain treatment instructions and diagnostic procedures.
Book Source Details
- Book Title: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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