Zenker's diverticulum differential diagnosis: Difference between revisions

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{{Zenker's diverticulum}}
[[Image:Home_logo1.png|right|250px|link=https://www.wikidoc.org/index.php/Zenker%27s_diverticulum]]
{{CMG}} {{AE}}
{{CMG}} {{AE}} {{Ajay}}


==Overview==
==Overview==
The differential diagnosis of the [[Zenker's diverticulum]] (ZD) are as follows [[Plummer-Vinson syndrome]], [[reflux esophagitis]], [[esophageal carcinoma]], [[Systemic sclerosis|systemic sclerosis,]] [[achalasia]], psuedoachalasia, [[chagas disease]], [[esophageal candidiasis]], [[pharyngitis]] and [[stroke]].


The differential diagnosis of the Zenker's diverticulum (ZD) are as follows Plummer-Vinson syndrome, reflux esophagitis, esophageal carcinoma, systemic sclerosis, achalasia, psuedoachalasia, chagas disease, esophageal candidiasis, pharyingitis and stoke.
==Differential Diagnosis==
==Differential Diagnosis==
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* Thin projections on the anterior [[esophageal]] wall
* Thin projections on the anterior [[esophageal]] wall
* Multiple upper [[Esophageal stricture|esophageal constrictions]]
* Multiple upper [[Esophageal stricture|esophageal constrictions]]
[[Image:Plummer-vinson-syndrome.jpg|center|200px|thumb|Barium esophagogram (Source: Case courtesy of Dr Hani Salam, <a href="https://radiopaedia.org/">Radiopaedia.org</a>. From the case <a href="https://radiopaedia.org/cases/14029">rID: 14029</a>)]]
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* Direct visualization of [[esophageal webs]]
* Direct visualization of [[esophageal webs]]
* Superior to [[esophagogram]]
* Superior to [[esophagogram]]
<div style="width:350px">{{#ev:youtube|HFfsTgsB6Pg}}</div>
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* Videofluoroscopy shows [[mucosal]] and [[submucosal]] foldings
* Videofluoroscopy shows [[mucosal]] and [[submucosal]] foldings
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*Fixed transverse folds
*Fixed transverse folds
*[[Esophageal]] intramural pseudodiverticula   
*[[Esophageal]] intramural pseudodiverticula   
[[Image:Benign-oesophageal-stricture.jpg|center|200px|thumb|Case courtesy of Dr Ahmed Abd Rabou, Radiopaedia.org, rID: 23008]]
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* [[Mucosal]] edema
* [[Mucosal]] edema
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* Pale [[mucosa]] with white [[exudate]] in lymphocytic esophagitis
* Pale [[mucosa]] with white [[exudate]] in lymphocytic esophagitis
* [[Swelling]] and [[hemorrhagic]] [[congestion]] in [[caustic]]<nowiki/> ingestion
* [[Swelling]] and [[hemorrhagic]] [[congestion]] in [[caustic]]<nowiki/> ingestion
<div style="width:350px">{{#ev:youtube|vax5E-jMnQ}}</div>
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* [[Manometry]] may show dysmotility
* [[Manometry]] may show dysmotility
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* Nonperistaltic and nonpropulsive contractions
* Nonperistaltic and nonpropulsive contractions
* Corkscrew or rosary bead esophagus
* Corkscrew or rosary bead esophagus
[[Image:DES radio.png|center|200px|thumb|Barium swallow appearance of DES<br>Source:By Nevit Dilmen [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)]]
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* Inconclusive
* Inconclusive
<div style="width:350px">{{#ev:youtube|2ipA34iMA3c}}</div>
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*[[Manometry]] shows high-amplitude [[esophageal]] contractions
*[[Manometry]] shows high-amplitude [[esophageal]] contractions
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* Air fluid level (absent [[peristalsis]])
* Air fluid level (absent [[peristalsis]])
* Absence of an intragastric air bubble
* Absence of an intragastric air bubble
[[Image:Achalasia-2.jpg|center|200px|thumb|Case courtesy of Dr Mario Umana, Radiopaedia.org, rID: 38071]]
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* Dilated [[esophagus]]
* Dilated [[esophagus]]
* Residual food fragments  
* Residual food fragments  
* Normal [[mucosa]]  
* Normal [[mucosa]]  
<div style="width:350px">{{#ev:youtube|ydLcskQzEjM}}</div>
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* Residual pressure of [[Lower esophageal sphincter|LES]] > 10 mmHg
* Residual pressure of [[Lower esophageal sphincter|LES]] > 10 mmHg
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* Thin projections on [[esophageal]] wall over [[Killian's dehiscence|Killian's triangle]]
* Thin projections on [[esophageal]] wall over [[Killian's dehiscence|Killian's triangle]]
[[Image:Zenker-4.jpg|center|200px|thumb| Radiopaedia.org">{{cite web |url=https://radiopaedia.org/cases/zenker-diverticulum |title=Zenker diverticulum &#124; Radiology Case &#124; Radiopaedia.org |format= |work= |accessdate=}}<nowiki></ref></nowiki>]]
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* Outpouching of posterior [[pharyngeal]] wall
* Outpouching of posterior [[pharyngeal]] wall


* Exclude the presence of [[Squamous cell carcinoma|SCC]]
* Exclude the presence of [[Squamous cell carcinoma|SCC]]
<div style="width:350px">{{#ev:youtube|FdEruFsNdVA}}</div> 
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* [[CT]] & [[MRI]] shows out-pouching over the posterior esophagus in the Killian's triangle
* [[CT]] & [[MRI]] shows out-pouching over the posterior esophagus in the Killian's triangle
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* Irregular [[Strictures|stricture]]
* Irregular [[Strictures|stricture]]
* Pre-stricture [[dilatation]]
* Pre-stricture [[dilatation]]
[[Image:Oesophageal-squamous-cell-carcinoma-2.jpg|center|200px|thumb|Case courtesy of Dr Bruno Di Muzio, Radiopaedia.org, rID: 4232f]]
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* [[Esophageal]] obstruction
* [[Esophageal]] obstruction
* Staging of disease
* Staging of disease
<div style="width:350px">{{#ev:youtube|5ucSlgqGAno}}</div>
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* [[CT]] and [[PET scan]] is an optional test for staging of the disease
* [[CT]] and [[PET scan]] is an optional test for staging of the disease
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* Barium [[esophagogram]]
* Barium [[esophagogram]]
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==References==
==References==
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[[Category:Needs patient information]]
[[Category:Needs patient information]]
[[Category:Disease]]
[[Category:Disease]]
[[Category:Differential diagnosis]]


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Latest revision as of 22:04, 7 February 2019

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Ajay Gade MD[2]]

Overview

The differential diagnosis of the Zenker's diverticulum (ZD) are as follows Plummer-Vinson syndrome, reflux esophagitis, esophageal carcinoma, systemic sclerosis, achalasia, psuedoachalasia, chagas disease, esophageal candidiasis, pharyngitis and stroke.

Differential Diagnosis

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Dysphagia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Oropharyngeal dysphagia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Esophageal dysphagia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Solids only
 
 
 
 
 
 
 
 
 
 
 
 
Solids and Liquids
 
 
 
 
 
 
 
 
 
 
Solids only
 
 
 
 
 
 
 
 
 
Solids and Liquids
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
•Zenker's diverticulum
•Neoplasm
•Webs
 
 
 
 
 
 
 
 
 
Neurogenic
 
 
 
Myogenic
 
 
 
 
 
 
 
Pain
 
 
 
 
 
 
 
 
 
•Achalasia
•Scleroderma
•DES
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
•Myasthenia gravis
•Connective tissue disorder
•Myotonic dystrophy
 
 
 
 
No
 
 
 
 
Yes
 
 
 
 
 
Heart burn
 
 
 
 
 
 
 
Barium swallow
 
 
 
 
 
 
 
 
 
Mental status
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
•Pill esophagitis
•Caustic injury
•Chemotherapy
 
 
Yes
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Impaired
 
 
 
Normal
 
 
 
 
Non progressive
 
 
 
Progressive
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Sac
 
 
Webs
 
 
Mass
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Scleroderma
 
 
 
•Achalasia
•DES
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Stroke
 
 
 
•ALS
•Parkinsonism
 
 
 
 
•Rings
•Webs
 
 
 
•Strictures
•Cancer
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Zenker's diverticulum
 
 
Plummer-Vinson syndrome
 
 
Carcinoma
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Chest pain and manometry
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Barium swallow
 
 
 
Weight loss
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Increase LES pressure
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Rings
 
 
 
Webs
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Rapid
 
 
 
Slow
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Achalasia
 
 
 
DES
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cancer
 
 
 
Strictures/GERD
 
 
 
 
 
 


Zenker's diverticulum must be differentiated from other diseases that cause dysphagia such as reflux esophagitis, esophageal carcinoma, systemic sclerosis, esophageal spasm, pseudoachalasia, stroke, esophageal candidiasis and Chagas disease.[1][2][3][4][5][6][7][8][9][10][11]

Disease Signs and Symptoms Barium esophagogram Endoscopy Other imaging and laboratory findings Gold Standard
Onset Dysphagia Weight loss Heartburn Other findings Mental status
Solids Liquids Type
Plummer-Vinson syndrome
  • Gradual
 + - Non progressive +/- - Normal

Triad of

Esophageal stricture
  • Gradual
  • Sudden onset
 + - Progressive +/- +/- Normal
  • Sacculations
  • Fixed transverse folds
  • Esophageal intramural pseudodiverticula   
Diffuse esophageal spasm
  • Sudden
 + + Non progressive + + Normal
  • Nonperistaltic and nonpropulsive contractions
  • Corkscrew or rosary bead esophagus
  • Inconclusive
Achalasia
  • Gradual
 + + Non progressive +/- - Normal
  • "Bird's beak" or "rat tail" appearance
  • Dilated esophageal body
  • Air fluid level (absent peristalsis)
  • Absence of an intragastric air bubble
  • Residual pressure of LES > 10 mmHg
  • Incomplete relaxation of the LES
  • Increased resting tone of LES
  • Aperistalsis
Systemic sclerosis
  • Gradual
 + + Progressive +/- + Normal
  • Dysmotility
  • Peptic stricture (advanced cases)
 Positive serology for
Zenker's diverticulum
  • Gradual
 + - +/- - Normal
  • Exclude the presence of SCC
  • CT & MRI shows out-pouching over the posterior esophagus in the Killian's triangle
Esophageal carcinoma
  • Gradual
 + + Progressive + +/- Normal
  • CT and PET scan is an optional test for staging of the disease
Stroke

(Cerebral hemorrhage)

  • Sudden
 + + Progressive + +/- Impaired
Motor disorders

(Myasthenia gravis)

  • Gradual
 + + Progressive +/- Normal
  • Stasis in pharynx and pooling in pharyngeal recesses
  • Anti–acetylcholine receptor antibody test
GERD
  • Gradual
  • Sudden onset
 + - Progressive +/- + Normal
Esophageal web
  • Gradual
 + +/- Progressive - +/- Normal
  • Smooth membrane not encircling the whole lumen

References

  1. ↑ Ferri, Fred (2015). Ferri's clinical advisor 2015 : 5 books in 1. Philadelphia, PA: Elsevier/Mosby. ISBN 978-0323083751.
  2. ↑ Boeckxstaens GE, Zaninotto G, Richter JE (2013). "Achalasia". Lancet. doi:10.1016/S0140-6736(13)60651-0. PMID 23871090.
  3. ↑ Badillo R, Francis D (2014). "Diagnosis and treatment of gastroesophageal reflux disease". World J Gastrointest Pharmacol Ther. 5 (3): 105–12. doi:10.4292/wjgpt.v5.i3.105. PMC 4133436. PMID 25133039.
  4. ↑ Napier KJ, Scheerer M, Misra S (2014). "Esophageal cancer: A Review of epidemiology, pathogenesis, staging workup and treatment modalities". World J Gastrointest Oncol. 6 (5): 112–20. doi:10.4251/wjgo.v6.i5.112. PMC 4021327. PMID 24834141.
  5. ↑ Matsuura H (2017). "Diffuse Esophageal Spasm: Corkscrew Esophagus". Am. J. Med. doi:10.1016/j.amjmed.2017.08.041. PMID 28943381.
  6. ↑ Lassen JF, Jensen TM (1992). "[Corkscrew esophagus]". Ugeskr. Laeg. (in Danish). 154 (5): 277–80. PMID 1736462.
  7. ↑ Ruigómez A, García Rodríguez LA, Wallander MA, Johansson S, Eklund S (2006). "Esophageal stricture: incidence, treatment patterns, and recurrence rate". Am. J. Gastroenterol. 101 (12): 2685–92. doi:10.1111/j.1572-0241.2006.00828.x. PMID 17227515.
  8. ↑ Shami VM (2014). "Endoscopic management of esophageal strictures". Gastroenterol Hepatol (N Y). 10 (6): 389–91. PMC 4080876. PMID 25013392.
  9. ↑ López Rodríguez MJ, Robledo Andrés P, Amarilla Jiménez A, Roncero Maíllo M, López Lafuente A, Arroyo Carrera I (2002). "Sideropenic dysphagia in an adolescent". J. Pediatr. Gastroenterol. Nutr. 34 (1): 87–90. PMID 11753173.
  10. ↑ Chisholm M (1974). "The association between webs, iron and post-cricoid carcinoma". Postgrad Med J. 50 (582): 215–9. PMC 2495558. PMID 4449772.
  11. ↑ Larsson LG, Sandström A, Westling P (1975). "Relationship of Plummer-Vinson disease to cancer of the upper alimentary tract in Sweden". Cancer Res. 35 (11 Pt. 2): 3308–16. PMID 1192404.


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