Esophageal Diverticulum as a Cause of Upper Gastrointestinal Bleeding

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

Disclosures

October 24, 2003

Discussion

Esophageal diverticula can be categorized into various types. A true diverticulum contains all layers of the wall, whereas a false diverticulum represents herniation of the mucosa and submucosa through the muscular wall. Zenker's (hypopharyngeal) diverticula are located just above the upper esophageal sphincter.Mid-esophageal diverticula located 5 cm above and below the carina[4] are often related to underlying necrotic nodal infection (eg, tuberculosis, histoplasmosis, malignancy), and therefore are called traction diverticula. Epiphrenic diverticula located above the lower esophageal sphincter in the distal 10 cm of esophagus[5] are often associated with motility disorders (eg, diffuse esophageal spasm, achalasia),[6] obstruction, or wall weakness, and therefore are called pulsion diverticula. The majority of esophageal diverticula are acquired, epiphrenic, pulsion diverticula of the false type.

Most patients are asymptomatic,[1] but esophageal diverticula may cause dysphagia, regurgitation, halitosis, chest pain, and respiratory symptoms from aspiration.

Diverticular inflammation due to chronic stasis from food residue may result in ulceration, fistulae, and even bleeding.[2,3] Development of carcinoma in the diverticulum has been reported as well.[7]

Chest radiograph may show an air-fluid level in the chest, which may be mistaken for a hiatal hernia. Barium swallow will outline the diverticulum. EGD is often required, especially if surgery is contemplated. Esophageal manometry may be performed depending on the site of the diverticulum, clinical presentation, and the concern for underlying esophageal dysmotility.

No treatment is necessary for asymptomatic esophageal diverticula.[8] Surgery may be required for symptomatic diverticula, especially with aspiration, which carries a high mortality. Surgical options include resection of the diverticulum and/or myotomy. An incomplete gastric wrap is often performed to prevent gastroesophageal reflux resulting from the myotomy. Myotomy is the mainstay of treatment for pulsion diverticula.[8]

The site of myotomy depends on manometric findings, function of the lower esophageal sphincter, location of the diverticulum, and operator preference. The need for a concomitant antireflux procedure is debatable.

Bleeding from esophageal diverticula is a rare, but life-threatening complication and is amenable to endoscopic therapy as shown in our first case. Patients who fail endoscopic therapy or those who do not have a discrete bleeding site require surgery.

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