Zenker's diverticulum overview

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Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Zenker's diverticulum from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

X Ray

CT

MRI

Ultrasound

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

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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

1. Phrenoesophageal (Zenker's diverticulum-70%)

2. Epiphrenic (20%)

3. Thoracic and mediastinal (10%)

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

Complications

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]

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

  1. "Zenker's diverticulum: exploring treatment options".
  2. "Long-term survival following diverticulectomy for cancer in pharyngoesophageal (Zenker's) diverticulum. - PubMed - NCBI".
  3. "Esophageal diverticula and cancer. - PubMed - NCBI".
  4. "The treatment of pharyngoesophageal diverticulum: the simple and complex. - PubMed - NCBI".
  5. "Carcinoma arising in posterior pharyngeal pulsion diverticulum (Zenker's diverticulum). - PubMed - NCBI".
  6. 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.
  7. Stankiewicz C (2006). "[Hypopharyngeal Zenker's diverticulum as a clinical and surgical problem]". Otolaryngol Pol (in Polish). 60 (3): 295–303. PMID 16989439.
  8. 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.
  9. 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.
  10. 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.
  11. Al-Juboori AN, Al-Essawi SH (2013). "Zenker's diverticulum. A rare cause of dysphagia". Saudi Med J. 34 (1): 91–3. PMID 23299166.

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