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4 Esophageal Diverticula
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Diverticula may occur in the mid or distal esophagus These may arise secondary to motility disorders (diffuse esophageal spasm, achalasia) or may develop above esophageal strictures Diverticula are seldom symptomatic For patients with severe symptoms or pulmonary complications, surgical myotomy with or without diverticulectomy is the optimal treatment
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Zenker s Diverticulum
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Zenker s diverticulum is a protrusion of pharyngeal mucosa that develops at the pharyngoesophageal junction between the inferior pharyngeal constrictor and the cricopharyngeus The cause is believed to be loss of elasticity of the upper esophageal sphincter, resulting in restricted opening during swallowing Symptoms of dysphagia and regurgitation tend to develop insidiously over years in older patients Initial symptoms include vague oropharyngeal dysphagia with coughing or throat discomfort As the diverticulum enlarges and retains food, patients may note halitosis, spontaneous regurgitation of undigested food, nocturnal choking, gurgling in the throat, or a protrusion in the neck Complications include aspiration pneumonia, bronchiectasis, and lung abscess The diagnosis is best established by a barium esophagogram Symptomatic patients require upper esophageal myotomy and, in most cases, surgical diverticulectomy An intraluminal approach has been developed recently in which the septum between the esophagus and diverticulum is incised Significant improvement occurs in over 90% of patients treated surgically Small asymptomatic diverticula may be observed
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Altman JI et al Fiberoptic endoscopic-assisted diverticulotomy: a novel technique for the management of Zenker s diverticulum Ann Otol Rhinol Laryngol 2005 May;114(5):347 51 [PMID: 15966520] Cassivi SD et al Diverticula of the esophagus Surg Clin North Am 2005 Jun;85(3):495 503 [PMID: 15927646] Michael H et al Treatment of epiphrenic and mid-esophageal diverticula Curr Treat Options Gastroenterol 2004 Feb;7(1): 41 52 [PMID: 14723837]
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Esophageal webs are thin, diaphragm-like membranes of squamous mucosa that typically occur in the mid or upper esophagus and may be multiple They may be congenital but also occur with graft-versus-host disease, pemphigoid, epidermolysis bullosa, pemphigus vulgaris, and, rarely, in association with iron deficiency anemia (Plummer-Vinson syndrome) Esophageal Schatzki rings are smooth, circumferential, thin (< 4 mm in thickness) mucosal structures located in the distal esophagus at the squamocolumnar junction Their pathogenesis is controversial They are associated in nearly all cases with a hiatal hernia, and reflux symptoms are common, suggesting that acid gastroesophageal reflux may be contributory in many cases Most webs and rings are over 20 mm in diameter and are asymptomatic Solid food dysphagia most often occurs with rings less than 13 mm in diameter Characteristically, dysphagia is intermittent and not progressive Large poorly chewed food boluses such as beefsteak are most likely to cause symptoms Obstructing boluses may pass by drinking extra liquids or after regurgitation In some cases, an impacted bolus must be extracted endoscopically Esophageal webs and rings are best visualized using a barium esophagogram with full esophageal distention Endoscopy is less sensitive than barium esophagography The majority of symptomatic patients with a single ring or web can be effectively treated with the passage of a large (> 16-mm-diameter) bougie dilator to disrupt the lesion A single dilation may suffice, but repeat dilations are required in many patients Patients who have heartburn or who
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Benign tumors of the esophagus are quite rare They are submucosal, the most common being leiomyoma Most are asymptomatic and picked up incidentally on endoscopy or barium esophagography Larger lesions can cause dysphagia, pain, and rarely ulceration with bleeding The risk of malig-
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nant transformation is low Therefore, the major clinical importance of these lesions is to distinguish them from malignant neoplasms At endoscopy, a smooth, sessile nodule is observed with normal overlying mucosa Because the lesion is submucosal, endoscopic biopsies are generally nonrevealing Endoscopic ultrasonography is extremely helpful to confirm the submucosal origin of the tumor and to help distinguish benign leiomyomas from malignant leiomyosarcomas Surgical (or in selected cases endoscopic) resection is indicated for lesions that are symptomatic, ulcerated, or increasing in size
Lee LS et al Current management of esophageal leiomyoma J Am Coll Surg 2004 Jan;198(1):136 46 [PMID: 14698321]
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