History

Fact Explanation
Asymptomatic Mid-oesophageal diverticula are commonly asymptomatic because they are relatively small. Most of the esophageal diverticula are pulsion diverticula, which protrudes from a weak point of the esophageal musculature. This is common secondary to esophageal obstruction, abnormal motility and impaired relaxation of the esophagus which leads to increased pressure within the esophagus. [2]
Dysphagia and or odynophagia Compression of the esophagus by a large diverticulum (eg: Zenker’s diverticulum) can cause dysphagia and odynophagia. [2]
Regurgitation Patients complain of regurgitation of undigested food in to the mouth. Once swallowed, some amount of food is impacted within the diverticulum which then regurgitates especially when the patient stoops or lie down. [1,2,3]
Recurrent chest pain Some patients complain of non-specific chest pain. [1,2,3]
Dyspeptic symptoms Patients with epiphrenic diverticula can present with dyspeptic symptoms (heart burn and acid reflux). [1]
Swelling of the lateral side of the neck Zenker’s diverticulum which is not a true esophageal diverticulum can cause swelling and sensation of pressure over the lateral side of the neck. The mucosa of the esophagus protrudes posteriorly above the cricopharyngeal sphincter. The dehiscence of Killian is located between the oblique and horizontal cricopharyngeus fibres of the inferior pharyngeal constrictor, through which the diverticulum protrudes. [1]
Recurrent chocking and cough Choking can occur secondary to regurgitation of food particles into the airway. This is common during night. Development of fistula between the diverticulum and the airway can also cause choking and aspiration. [1,2,3]
Recurrent respiratory tract infections Patients with fistula between the diverticulum and the respiratory airways can present with recurrent attacks of aspiration pneumonia. Fever, cough, pleuritic chest pain are common complains of aspiration pneumonia. [2]
Presence of risk factors Patients with a history of tuberculosis can have traction diverticula, secondary to inflammation and scarring of the mediastinal lymph nodes. Esophageal spasm and achalasia are also considered as risk factors for the development of esophageal diverticula. Traction diverticula (true diverticula) are less common than pulsion diverticula. These occur secondary to external traction commonly caused by fibrosis and contraction of the tracheobronchial or mediastinal lymph nodes lymph nodes. [1,2][1,3]
References
  1. LAUBERT T, HILDEBRAND P, ROBLICK UJ, KRAUS M, ESNAASHARI H, WELLHöNER P, BRUCH HP. MIS approach for diverticula of the esophagus. Array [online] 2010 December [viewed 05 August 2014] Available from: doi:10.1186/2047-783X-15-9-390
  2. LóPEZ A. Esophagobronchial fistula caused by traction esophageal diverticulum. European Journal of Cardio-Thoracic Surgery [online] 2003 January, 23(1):128-130 [viewed 05 August 2014] Available from: doi:10.1016/S1010-7940(02)00666-8
  3. SILECCHIA G, CASELLA G, RECCHIA CL, BIANCHI E, LOMARTIRE N. Laparoscopic Transhiatal Treatment of Large Epiphrenic Esophageal Diverticulum JSLS [online] 2008, 12(1):104-108 [viewed 05 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3016038

Examination

Fact Explanation
Fever Patients with lower respiratory tract infection can be febrile. [1]
Signs of lower respiratory tract infection Reduced chest expansion, dull percussion note, increased tactile vocal fremitus and reduced breath sounds over the affected lobe are indicative of lobar consolidation. Aspiration pneumonia is common over the lower lobe of the right lung.
Neck swelling Zenker's diverticulum may bulge towards the lateral side of the neck. Swelling is more prominent after meals.
Upper lobe fibrosis Patients with a history of pulmonary tuberculosis can have evidence of right upper lobe fibrosis. Reduced chest expansion, tracheal shift to the side of the fibrosis, fine pulmonary crackles are indicative of upper lobe fibrosis.
Loss of weight Patients lose weight due to recurrent respiratory tract infections.
References
  1. SILECCHIA G, CASELLA G, RECCHIA CL, BIANCHI E, LOMARTIRE N. Laparoscopic Transhiatal Treatment of Large Epiphrenic Esophageal Diverticulum JSLS [online] 2008, 12(1):104-108 [viewed 05 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3016038

Differential Diagnoses

Fact Explanation
Gastroesophageal reflux disease (GERD) GERD can cause acid reflux, burning epigastric pain and regurgitation. Zenker's diverticulum can occur secondary to GERD as well. [1,2]
Achalasia Achalasia presents with dysphagia, regurgitation, chronic cough, choking and recurrent respiratory tract infections. Esophageal manometry is helpful in making the definitive diagnosis. [3]
Esophageal carcinoma Esophageal carcinoma should be considered as a possible differential diagnosis of patients presenting with dysphagia, especially in elderly. Dysphagia, loss of weight, loss of appetite, recurrent respiratory tract infections can be presenting complains of esophageal carcinoma. [4]
Chagas disease This results due to infection from Trypanosoma cruzi. Patients may also have features of infection in other myenteric plexuses as well. (megacolon and neurologic disorders.) [5]
References
  1. MAEDA TETSUYA, NAGATA KEN, SATOH YUICHI, YAMAZAKI TAKASHI, TAKANO DAIKI. High Prevalence of Gastroesophageal Reflux Disease in Parkinson’s Disease: A Questionnaire-Based Study. Parkinson's Disease [online] 2013 December, 2013:1-6 [viewed 05 August 2014] Available from: doi:10.1155/2013/742128
  2. MEHDI NIGHAT F, WEINBERGER MILES M, ABU-HASAN MUTASIM N. Achalasia: unusual cause of chronic cough in children. Array [online] 2008 December [viewed 05 August 2014] Available from: doi:10.1186/1745-9974-4-6
  3. KUGELMAN A, BERKOWITZ D, BEST LA, BENTUR L. Upper airway obstruction as a presenting sign of achalasia in childhood. [online] December, 89(3):356-364 [viewed 05 August 2014] Available from: doi:10.1111/j.1651-2227.2000.tb01338.x
  4. LAGERGREN JESPER, LAGERGREN PERNILLA. Recent developments in esophageal adenocarcinoma. CA A Cancer Journal for Clinicians [online] December, 63(4):232-248 [viewed 05 August 2014] Available from: doi:10.3322/caac.21185
  5. OLIVEIRA RICARDO BRANDT, TRONCON LUIZERNESTOA., DANTAS ROBERTOOLIVEIRA, MENEGHELLI ULYSSESG.. Gastrointestinal manifestations of chagas' disease. Am J Gastroenterology [online] 1998 June, 93(6):884-889 [viewed 05 August 2014] Available from: doi:10.1111/j.1572-0241.1998.270_r.x

Investigations - for Diagnosis

Fact Explanation
Barium swallow test Barium swallow test is useful in diagnosing the presence of esophageal diverticulum. It is also helpful in determining the site, size and the extent of the esophagus. Diverticula are visualized as outpouchings of the esophagus which are filled with contrast. Small conical outpouching is seen in mid thoracic traction diverticula. Zenker's diverticulum is seen as an outpouching of the posterior wall of distal pharynx near pharyngoesophageal junction (C5-C6 level), which is best seen in the lateral view. Barium swallow test have high accuracy and sensitivity in detecting esophageal diverticula. [1,2]
Upper gastrointestinal endoscopy (UGIE) UGIE is useful in measuring the diameter of the diverticulum's neck. [1]
CT scan CT scan of the mediastinum is also useful in diagnosing esophageal diverticula. Oral contrast can be used simultaneously for a better resolution of imaging. [3]
Esophageal manometry Esophageal manometry can detect the presence of esophageal motility disorders. Increased lower esophageal sphincter pressure, intraluminal pressure and non-propagating contractile waves are suggestive of esophageal motility disorder leading to pulsion diverticulum. [1]
24 h monitoring of pH Significant acid reflux can be seen in patients with epiphrenic (just above the diaphragm) diverticula. [1]
References
  1. LAUBERT T, HILDEBRAND P, ROBLICK UJ, KRAUS M, ESNAASHARI H, WELLHöNER P, BRUCH HP. MIS approach for diverticula of the esophagus. Array [online] 2010 December [viewed 05 August 2014] Available from: doi:10.1186/2047-783X-15-9-390
  2. CIOFFI UGO, DE SIMONE MATILDE, LEMOS ALESSANDRO, GALLIERA MAURIZIO. Bilateral Zenker's diverticulum plus middle esophageal diverticulum. European Journal of Cardio-Thoracic Surgery [online] 2007 October, 32(4):659-659 [viewed 05 August 2014] Available from: doi:10.1016/j.ejcts.2007.06.038
  3. LóPEZ A. Esophagobronchial fistula caused by traction esophageal diverticulum. European Journal of Cardio-Thoracic Surgery [online] 2003 January, 23(1):128-130 [viewed 05 August 2014] Available from: doi:10.1016/S1010-7940(02)00666-8

Investigations - Fitness for Management

Fact Explanation
Full blood count Patients can have anemia which should be corrected before surgery.
References

Management - General Measures

Fact Explanation
Health education Patients should be educated about the risk of recurrent aspiration and lower respiratory tract infection. Patients should be advised not to lie down or to stoop soon after meals. Elevation of the head-end of the bed and using few pillows will also help to minimize the risk of aspiration.
References

Management - Specific Treatments

Fact Explanation
Conservative management Patients with asymptomatic and small esophageal diverticula can be managed conservatively. [3]
Surgery Symptomatic patients with esophageal diverticula are eligible for surgical repair. Minimally invasive surgical treatment options are done with thoracoscopic, laparoscopic and endoscopic approaches. Pulsion diverticula is treated with myotomy of the sphincter in addition to resection of the diverticulum, because it is associated with impaired relaxation of the sphincter. Zenker's diverticula can be treated with endoluminal resection because of their close proximity to the larynx. Endoscopic stapling of the neck of the diverticulum is another minimally invasive treatment option. Open surgery should be done for symptomatic midesophageal and epiphrenic diverticula. Traction diverticula are treated with excision of the diverticulum and the inflammatory mass. [1,2,3]
References
  1. LAUBERT T, HILDEBRAND P, ROBLICK UJ, KRAUS M, ESNAASHARI H, WELLHöNER P, BRUCH HP. MIS approach for diverticula of the esophagus. Array [online] 2010 December [viewed 05 August 2014] Available from: doi:10.1186/2047-783X-15-9-390
  2. LóPEZ A. Esophagobronchial fistula caused by traction esophageal diverticulum. European Journal of Cardio-Thoracic Surgery [online] 2003 January, 23(1):128-130 [viewed 05 August 2014] Available from: doi:10.1016/S1010-7940(02)00666-8
  3. AHUJA V, YENCHA MW, LASSEN LF. Head and neck manifestations of gastroesophageal reflux disease. Am Fam Physician [online] 1999 Sep 1, 60(3):873-80, 885-6 [viewed 05 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10498113