Zenkers diverticulum

INTRODUCTION:
  • Zenker's diverticulum, also pharyngoesophageal diverticulum, also pharyngeal pouch, also hypopharyngeal diverticulum, 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 pulsion diverticulum i.e caused by an increased intraluminal pressure in the esophagus (secondary to abnormal motility of esophagus) which push the mucosa and submucosa through the muscular defect.
  • Zenker diverticulum originates from the posterior wall of the esophagus in a triangular area of weakness, limited inferiorly by the cricopharyngeus muscle and superiorly by the inferior constrictor muscles (ie, the Killian triangle).
  • As the diverticulum enlarges, it tends to deviate from the midline, mostly to the left
  • It is a pseudo diverticulum (not involving all layers of the esophageal wall).
  • Seen in 50years old
SIGNS & SYMPTOMS:
  • While it may be asymptomatic, Zenker diverticulum can present with the following symptoms:
  1. Dysphagia (difficulty swallowing), and sense of a lump in the throat
  2. Food might get trapped in the outpouching, leading to:
  3. Regurgitation, reappearance of ingested food in the mouth
  4. Cough, due to food regurgitated into the airway
  5. Halitosis, smelly breath, as stagnant food is digested by microorganisms
  6. Infection
  • It rarely, if ever, causes any pain.
  • Cervical webs are seen associated in 50% of patients with this condition.
FORMS OF ZENKER'S DIVERTICULUM:
  • Killian's diverticulum
  • It is formed in the Killian-Jamiseon triangle (located inferior to the cricopharyngeus on both sides of this muscle's insertion into the cricoid cartilage).
  • Laimer's diverticulum
  • It is formed in Laimer's triangle (located inferior to the cricopharyngeus in the posterior midline above the confluence of the longitudinal layer of esophageal muscle). Laimer's triangle is covered only by the circular layer of esophageal muscle.
COMPLICATIONS:
  • Pulmonary infection is the most frequent serious complication, and many patients are first seen after experiencing repeated episodes of pneumonia.
  • Aspiration pneumonia & Lung abscess are the most frequent complications of Zenker's diverticulum.
  • Other rare complications are:
  • Perforation
  • Bleeding
  • Carcinoma
DIAGNOSIS:
  1. The simple barium swallow will normally reveal the diverticulum.
  2. It may also be found with upper GI endoscopy, or CT with oral contrast.
TREATMENT:
  • Neck surgery to resect the diverticulum and incise the cricopharyngeus muscle.
  • Non-surgical endoscopic techniques and the currently preferred treatment is endoscopic stapling (i.e. diverticulotomy with staples ). This may be performed through a diverticuloscope. Other methods include fibreoptic diverticular repair
  • Other non-surgical treatment modalities also exist, such as endoscopic laser
Exam Question
  • Zenkers diverticulum is also called as Pharyngoesophageal diverticulum, pharyngeal pouch & hypopharyngeal diverticulum
  • An aged patient with symptoms of foul breath & regurgitation of food which is eaten 3 days ago, it is a typical presentation of Zenker's diverticulum.
  • Zenkers diverticulum is an acquired, false, pulsion diverticulum that affects patients older than 50 years
  • Lateral X-rays on barium swallow are often diagnostic of Zenkers diverticulum
  • Zenkers diverticulum is an outpouching in the posterior pharyngeal wall immediately above upper esophageal sphincter
  • Zenkers diverticulum when enlarges, it tends to deviate from the midline, mostly to the left
  • Zenker’s diverticulum originates from the posterior wall of the esophagus through triangular area of weakness
  • Treatment of Zenker’s diverticulum is simple excision
  • Commonest complication of Zenker's diverticulum is Aspiration pneumonia & Lung abscess
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