Zenker's diverticulum overview
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief:
Overview
In anatomy, Zenker's diverticulum, also pharyngoesophageal diverticulum, also pharyngeal pouch, is a diverticulum of the mucosa of the pharynx, just above the cricopharyngeal muscle (i.e. above the upper sphincter of the esophagus). It is a false diverticulum (not involving all layers of the esophageal wall).
Historical Perspective
he first description of Zenker's diverticulum dates back to 1769 by Ludlow.
Classification
- Esophageal diverticula are classified on the basis of location into three types
- Almost all esophageal diverticula are acquired pulsion diverticula.
1. Phrenoesophageal (Zenker's diverticulum-70%)
- ZD is a defect over the Killian's triangle, a point of weakness in the muscular wall of the hypopharynx.
2. Epiphrenic (20%)
- Epinephric diverticula result either from hypertonia of the lower esophageal sphincter (esophageal achalasia)
3. Thoracic and mediastinal (10%)
- Thoracic diverticula are probably more often of a congenital than traction origin.
Pathophysiology
Zenker's diverticulum (ZD) is thought to be due to the result of motor abnormalities of the esophagus. The defect over the Killian's triangle, a point of weakness in the muscular wall of the hypopharynx results in ZD. Killian's triangle is surrounded by the cricopharyngeal sphincter and oblique fibers of the inferior constrictor of the pharyngeal muscle. It is considered a pseudodiverticulum as it includes only mucosa and submucosa. Chronic strain on the Killian's triangle leads to an evagination of the sphincter, which may be because of the high pressures in the food bolus in the course of swallowing and the abnormalities of the upper esophageal sphincter (UES). This failure to achieve adequate diameter for effective bolus clearance leads to a subsequent increase in the hypopharyngeal pressure gradient. Increased intra-bolus pressures found in patients with ZD can be secondary to impaired bolus passage combined with the gastroesophageal reflux disease (GERD) or as a result of the GERD. As the diverticulum enlarges, it may compress the pharyngoesophageal segment as well as increased stiffness and the intrabolus pressure. Increased intrabolus pressure is also increased in older patients who perform multiple swallows to achieve bolus clearance. Acid reflux is thought to lead to increased spasm of the UES which in turn increases the intra-bolus pressures during swallowing, given that swallowing is frequently distinct from episodes of acid reflux disease.
Causes
Zenker's diverticulum (ZD) also known as pharyngosophageal diverticulum. It is an acquired sac-like outpouching of the mucosa and submucosa layers originating from the pharyngoesophageal junction. Killian's dehiscence a pulsion of false diverticulum occurring dorsally at the pharyngoesophageal wall surrounded by the oblique inferior pharyngeal constrictor muscle and the transversal fibers of the cricopharyngeal muscle. ZD occurs due to increased intraluminal pressure in the oropharynx during swallowing, against an inadequate relaxation of the cricopharyngeal muscle. An incomplete opening of the Upper Esophageal Sphincter (UES) causing the protrusion of the mucosa through an area of relative weakness at the dorsal pharyngoesophageal wall. The pharyngoesophageal phase of swallowing is affected in ZD resulting in hindering the neuromuscular functions such as chewing, initiating the swallowing, and propulsion of the food from the oropharynx into the cervical esophagus.
Differentiating Zenker's diverticulum from Other Diseases
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.
Epidemiology and Demographics
Risk Factors
The risk factors of the Zenker's diverticulum (ZD) are as follow people in their seventh and eight decades, male, GERD, pre-existing hiatal hernia, esophageal motility disorder, esophagitis, neurological disorders like a stroke.
Screening
There is insufficient evidence to recommend routine screening for Zenker's diverticulum (ZD).
Natural History, Complications, and Prognosis
Natural History
- Symptoms of Zenker's diverticulum slowly start as a[1]
- Oropharyngeal dysphagia progressing from solids to liquids
- Regurgitation of undigested food from the diverticular sac
- Pharyngeal stasis of secretion
- Chronic aspiration
- Halitosis
- Chronic cough
- Sensation of a lump in the throat
- Hoarseness
- Cervical borborygmi.
- The patient may note food on the pillow upon awakening in the morning.
- Although small diverticula may not cause symptoms, larger diverticula usually are symptomatic.
- Both the inability of the sphincter to fully open and the extrinsic compression from the pouch itself are likely to explain the dysphagia experienced by patients.
- In patients with very large diverticula, a gurgling swelling in the neck can occasionally be detected on palpation.
Complications
- Complications of the Zenker's diverticulum includes[2][3][4][5]
- Aspiration pneumonia
- Bleeding of the diverticulum
- Ulceration of the diverticulum
- Compression of the trachea and esophageal obstruction with large diverticula
- Very rarely Squamous cell carcinoma of the diverticulum
- Perforation of the diverticulum during the endoscopy and hence scopes with side viewing should be used to prevent perforation.
Prognosis
Prognosis of ZD after the intervention is good, the recurrence of the diverticulum is very rare.
Diagnosis
Diagnostic Criteria
History and Symptoms
While it may be asymptomatic, Zenker diverticulum often causes clinical manifestations such as dysphagia, globus sensation, regurgitation, cough, halitosis,odynophagia.
Physical Examination
While it may be asymptomatic, Zenker diverticulum often causes clinical manifestations such as the following:[6][7][8][9][10][11]
- Dysphagia: difficulty swallowing
- Globus: a sense of a lump in the neck
- Regurgitation: reappearance of ingested food in the mouth due to the pouch filling up
- Cough: as some food may be regurgitated into the airways
- Halitosis: smelly breath, as stagnant food is digested by microrganisms
- Odynophagia or pain with swallowing is generally not present
Laboratory Findings
Laboratory studies are not helpful in the diagnosis of the Zenker's Diverticulum (ZD), whereas they are used for the upper esophageal webs associated with iron deficiency anemia. The laboratory tests are done to differentiate the ZD from Plummer- Vinson syndrome. Laboratory findings consistent with the diagnosis of Plummer-Vinson syndrome include presence of iron deficiency anemia
Imaging Findings
X-ray
An x-ray (barium esophagogram) is the best initial imaging study in a patient suspected with Zenker's Diverticulum (ZD). Findings on an x-ray (barium esophagogram) suggestive of esophageal diverticulum associated with ZD appear as thin projections on the anterior esophageal wall over the Killian's triangle.
CT scan
Zenker's diverticulum (ZD) appears as an out-pouching sac on the CT scan over the posterior esophagus in the Killian's triangle, a point of weakness in the muscular wall of the hypopharynx surrounded by the cricopharyngeal sphincter and oblique fibers of the inferior constrictor of the pharyngeal muscle.
MRI
Zenker's diverticulum (ZD) appears as an out-pouching sac on the MRI scan over the posterior esophagus in the Killian's triangle, a point of weakness in the muscular wall of the hypopharynx surrounded by the cricopharyngeal sphincter and oblique fibers of the inferior constrictor of the pharyngeal muscle. The sac is filled with, fluid, food, contrast materials.
Other Diagnostic Studies
Treatment
Medical Therapy
No medical treatment is currently known or practiced for symptomatic Zenker diverticulum.
Surgery
Surgery is the most definitive therapy for the Zenker's diverticulum (ZD). If small and asymptomatic, no treatment is necessary. Larger, symptomatic cases of Zenker's diverticulum have been traditionally treated by neck surgery to resect the diverticulum and incise the cricopharyngeus muscle. However, in recent times non-surgical endoscopic techniques have gained more importance, and the currently preferred treatment is the endoscopic stapling i.e. closing of the diverticulum via a stapler inserted through a tube in the mouth. This may be performed through a fiberoptic endoscope. Other non-surgical treatment modalities exist, such as endoscopic laser, which recent evidence suggests it less effective than stapling.
Prevention
There are no established measures for the primary prevention of Zenker's Diverticulum (ZD).
References
- ↑ "Zenker's diverticulum: exploring treatment options".
- ↑ "Long-term survival following diverticulectomy for cancer in pharyngoesophageal (Zenker's) diverticulum. - PubMed - NCBI".
- ↑ "Esophageal diverticula and cancer. - PubMed - NCBI".
- ↑ "The treatment of pharyngoesophageal diverticulum: the simple and complex. - PubMed - NCBI".
- ↑ "Carcinoma arising in posterior pharyngeal pulsion diverticulum (Zenker's diverticulum). - PubMed - NCBI".
- ↑ Hussain T, Maurer JT, Lang S, Stuck BA (2017). "[Pathophysiology, diagnosis and treatment of Zenker's diverticulum]". HNO (in German). 65 (2): 167–176. doi:10.1007/s00106-016-0302-z. PMID 27933354.
- ↑ Stankiewicz C (2006). "[Hypopharyngeal Zenker's diverticulum as a clinical and surgical problem]". Otolaryngol Pol (in Polish). 60 (3): 295–303. PMID 16989439.
- ↑ Ferreira LE, Simmons DT, Baron TH (2008). "Zenker's diverticula: pathophysiology, clinical presentation, and flexible endoscopic management". Dis. Esophagus. 21 (1): 1–8. doi:10.1111/j.1442-2050.2007.00795.x. PMID 18197932.
- ↑ Law R, Katzka DA, Baron TH (2014). "Zenker's Diverticulum". Clin. Gastroenterol. Hepatol. 12 (11): 1773–82, quiz e111–2. doi:10.1016/j.cgh.2013.09.016. PMID 24055983.
- ↑ Elbalal M, Mohamed AB, Hamdoun A, Yassin K, Miskeen E, Alla OK (2014). "Zenker's diverticulum: a case report and literature review". Pan Afr Med J. 17: 267. doi:10.11604/pamj.2014.17.267.4173. PMC 4191700. PMID 25309667.
- ↑ Al-Juboori AN, Al-Essawi SH (2013). "Zenker's diverticulum. A rare cause of dysphagia". Saudi Med J. 34 (1): 91–3. PMID 23299166.