Authors: Mihir S. Wagh, MD, David L. Carr-Locke, MD, FRCPSeries Editor: David L. Carr-Locke, MD, FRCP


October 24, 2003

Introduction and Case Presentations

Esophageal diverticula are outpouchings of 1 or more layers of the esophageal wall. Approximately 65% of diverticula are asymptomatic[1] and are often discovered incidentally during upper endoscopy performed for unrelated causes. A small proportion may present with life-threatening bleeding.[2,3] We report 2 patients with esophageal diverticular bleeding, 1 treated successfully with endoscopy and the other requiring surgery.

A 72-year-old woman with a past history of severe peripheral vascular disease, coronary artery disease, and atrial fibrillation, on warfarin and clopidogrel therapy, presented with melena of a few days' duration, followed by hematemesis on the morning of admission. She had a blood pressure of 110/60 mm Hg and a heart rate of 130 beats per minute. Her hematocrit was 18.1% and international normalized ratio was 9.0.

An emergent esophagogastroduodenoscopy (EGD) was performed, which revealed an epiphrenic esophageal diverticulum (Figure 1) with an ulcer and a nonbleeding visible vessel and blood clot.

The clot was washed off and revealed another nonbleeding visible vessel. Endoscopic hemoclips were successfully applied (Figure 2). The stomach and duodenum appeared normal. The patient did well post procedure and a follow-up EGD in 6 weeks showed the diverticulum with a well-healed ulcer (Figure 3).

A 70-year-old man with a history of coronary artery disease, on aspirin and clopidogrel therapy, was referred for evaluation of occult blood-positive stool and anemia requiring blood transfusions. Colonoscopy revealed nonbleeding colonic polyps. EGD showed oozing from a mid-esophageal diverticulum with food residue (Figure 4). No discrete bleeding site amenable for endoscopic therapy was identified. Treatment with iron and a proton-pump inhibitor was started. A small bowel follow-through was normal.

A follow-up EGD in 6 weeks showed findings similar to those seen on previous EGD. Due to persistent anemia, surgical evaluation was obtained and surgery was planned. Preoperative barium swallow confirmed the mid-esophageal diverticulum. A computerized tomogram of the chest (Figure 5) showed a subcarinal calcific mass, most likely reflecting chronic calcific granulomatous lymph nodes, adjacent to the esophageal diverticulum.

Esophageal diverticulectomy was performed (Figure 6). Calcific hard lymph nodes were identified attached to the diverticulum.