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:
• Dysphagia (difficulty swallowing), and sense of a lump in the throat
• Food might get trapped in the outpouching, leading to:
• Regurgitation, reappearance of ingested food in the mouth
• Cough, due to food regurgitated into the airway
• Halitosis, smelly breath, as stagnant food is digested by microorganisms
• 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:

• The simple barium swallow will normally reveal the diverticulum.
• 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