Esophageal Diverticulum

Oesophageal diverticula are outpouchings of the oesophageal wall, classified by location: pharyngoesophageal (Zenker), midoesophageal (traction), and epiphrenic (pulsion, distal).

• Midoesophageal: usually true diverticula (traction) from mediastinal inflammatory nodes (tuberculosis, histoplasmosis) pulling the wall, or pulsion due to motility disorder; often asymptomatic.
• Epiphrenic: within 10 cm of the gastro oesophageal junction, pulsion diverticula caused by distal outflow obstruction or motility disorder (achalasia, diffuse oesophageal spasm, hypercontractile oesophagus), found in 0.015% of the population.
• Complications: dysphagia, regurgitation, aspiration, bleeding, perforation, diverticulitis, carcinoma (rare, 0.3 to 3%).
• Intramural pseudodiverticulosis is a different entity (multiple small flask shaped outpouchings with candida oesophagitis, strictures).

• Most midoesophageal diverticula are asymptomatic.
• Epiphrenic: dysphagia, regurgitation, chest pain, nocturnal cough, aspiration, halitosis, weight loss; symptoms often due to the underlying motility disorder.
• Retrosternal discomfort after meals, rare haematemesis.
• Features of tuberculosis or lung disease for traction diverticula.

• Barium oesophagram: outpouching at the level (midoesophageal) or distal oesophagus on the right (epiphrenic, 2 to 3 cm above the diaphragm), neck and size, retained contrast.
• Upper endoscopy with caution to rule out neoplasia and inflammation; biopsy if abnormal.
• High resolution manometry to identify the underlying motility disorder (achalasia, spasm), essential before treatment.
• CT chest for mediastinal nodes or inflammatory mass and extent.
• Tuberculosis and fungal evaluation for traction diverticula.
• pH impedance monitoring for coexisting reflux.

• Asymptomatic: no treatment.
• Symptomatic epiphrenic diverticulum: treat the motor disorder.
  • Laparoscopic or thoracoscopic diverticulectomy combined with Heller myotomy (myotomy extended across the lower oesophageal sphincter, opposite the diverticulum) and partial fundoplication, resulting in good outcomes in 80 to 90%, with leak rate 5 to 20%.
  • Peroral endoscopic myotomy with or without diverticulotomy (D-POEM) as less invasive approach.
  • Diverticulopexy or invagination for small, symptomatic pouches.
• Midoesophageal symptomatic: treat motor disorder; surgery (diverticulectomy) if large (over 5 cm) or complicated; treat the underlying infection or inflammation.
• Endoscopic therapy: diverticulotomy, clip closure.
• Perioperative antibiotics (cefazolin 2 g), bowel rest, contrast swallow before oral feeding to exclude leak.
• Complications: leak, mediastinitis (urgent drainage, broad spectrum antibiotics such as piperacillin tazobactam 4.5 g every 6 hours, nil by mouth), recurrence.
• PPI for reflux, dietary modification.