Definition, Etiology, Epidemiology Top
Esophageal diverticula may develop when the esophageal wall is pushed from inside (pulsion diverticula) or pulled from outside (traction diverticula). Pushing forces are believed to occur more often in the hypopharynx and distal esophagus. In the midesophageal area diverticula are thought to be associated with “traction” processes, for example, from hilar or mediastinal inflammation.
Esophageal diverticula are classified according to their location: Zenker diverticula occur right above the upper esophageal sphincter, midesophageal diverticula are within 5 cm of the carina, and epiphrenic diverticula occur within the distal 10 cm of the esophagus.
Although the first case of an esophageal diverticulum was reported over 200 years ago, relatively little is known about this phenomenon and its natural history. Esophageal diverticula are mostly asymptomatic with an estimated frequency from 0.02% to 0.77%.
Most patients present in the sixth and seventh decades of life with dysphagia or regurgitation. Other common clinical features may include cough, halitosis (bad breath), and laryngitis. Life-threatening complications (eg, aspiration pneumonia, stridor, cardiac arrhythmias, cancer, diverticular rupture) are rare. Of all patients who present with dysphagia, only a minority (1%-3%) have an esophageal diverticulum as the identified cause; other processes are more common, including benign strictures, esophageal rings or webs, tumors, and motility disorders such as achalasia.
Different modalities may detect esophageal diverticula, including plain radiography, barium studies, computed tomography (CT), magnetic resonance imaging (MRI), or endoscopy. Zenker diverticula may present unexpectedly during endoscopy, causing difficult esophageal intubation and possibly perforation if they are not recognized.
Most patients can be followed conservatively and require no specific therapy. Surgery may be an option for patients with significant progressive dysphagia or recurrent aspiration pneumonia. For Zenker diverticula, novel endoscopic techniques have been developed as alternatives to surgery.