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Zenker's (pharyngoesophageal) diverticulum

Epidemiology: - generally occurs in patients > 50 years of age (generally men) [5] Pathology: - development of diverticulum in a natural area of weakness in the posterior hypopharyngeal wall between the cricopharyngeus & thyropharyngeus [5] Clinical manifestations: 1) dysphagia for solid & liquid foods - may be especially prominent in the cervical region 2) regurgitation of undigested food & pills (consumed on previous days) - regurgitated food may be foul smelling [5] 3) halitosis 4) fullness of the neck during meals - may be palpable neck mass [5] 5) gurgling noise in the throat [5] 6) no choking or a sensation that food is stuck 7) pulmonary aspiration 8) develops slowly 9) duration of symptoms: from weeks to years (case of 5 years) [11] Radiology: 1) barium swallow (image) [6] 2) endoscopy (after barium swallow) to rule out malignancy & mucosal abnormalities prior to surgical correction -> often done fluoroscopically over a guide wire to minimize risk of perforation Complications: 1) aspiration pneumonia 2) significant weight loss 3) esophageal compression -> esophageal obstruction 4) fistula Management: - surgery (no consensus regarding best surgical approach) a) diverticulectomy (diverticulectomy hypopharynx/esophagus) b) diverticulotomy with cricopharyngeal myotomy c) diverticular inversion with myotomy d) myotomy alone - peroral endoscopic myotomy (POEM) [7]

General

esophageal disease diverticulum

References

  1. UCLA Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
  2. Geriatrics Review Syllabus, American Geriatrics Society, 5th edition, 2002-2004 - Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013
  3. Al-Kadi AS, Maghrabi AA, Thomson D, Gillman LM, Dhalla S. Endoscopic treatment of Zenker diverticulum: results of a 7-year experience. J Am Coll Surg. 2010 Aug;211(2):239-43 PMID: 20670862
  4. Brace M, Taylor SM, Trites JR, Bethune D, Attia E, Hart RD. Endoscopic stapling versus external transcervical approach for the treatment of Zenker diverticulum. J Otolaryngol Head Neck Surg. 2010 Feb;39(1):102-6. PMID: 20122352
  5. Medical Knowledge Self Assessment Program (MKSAP) 17, 18, 19. American College of Physicians, Philadelphia 2015, 2018, 2022
  6. Le Mouel JP, Fumery M Zenker's Diverticulum. N Engl J Med 2017; 377:e31. Nov 30, 2017 PMID: 29171816 http://www.nejm.org/doi/full/10.1056/NEJMicm1701620
  7. Yang J, Novak S, Ujiki M et al. An international study on the use of peroral endoscopic myotomy in the management of Zenker's diverticulum. Gastrointest Endosc 2019 May 10; PMID: 31082393 https://www.giejournal.org/article/S0016-5107(19)31680-3/pdf
  8. Mayo clinic: Treatment of Zenker's diverticulum https://www.mayoclinic.org/medical-professionals/digestive-diseases/news/treatment-of-zenkers-diverticulum/mac-20431393
  9. Hannan SA, Alusi G Images in Clinical Medicine. Zenker's Diverticulum. N Engl J Med. 2006 Jun 8;354(23):e24. PMID: 16760438 https://www.nejm.org/doi/pdf/10.1056/NEJMicm050445
  10. Law R, Katzka DA, Baron TH. Zenker's Diverticulum. Clin Gastroenterol Hepatol. 2014 Nov;12(11):1773-82; PMID: 24055983 Review.
  11. NEJM Knowledge+