GI Endoscopy · 1 min read
Zenker
Dysphagia in an Elderly Patient
Experienced teaching points
Clinical Pearls
- Zenker's diverticulum is a false diverticulum, consisting only of herniated mucosa and submucosa that protrudes posteriorly through Killian's triangle.
- This herniation occurs in an area of natural weakness located above the cricopharyngeus muscle (the upper esophageal sphincter) and below the inferior pharyngeal constrictor.
- Patients classically present with dysphagia to solids, halitosis, and the dangerous nocturnal regurgitation of undigested food, which carries a significant risk for aspiration pneumonia.
An elderly man presented with dysphagia to solids. The patient also complained of partially digested food drooling out of his mouth while he slept. A barium esophagogram revealed a 40-mm posterior protrusion at the level of the proximal cervical esophagus. On EGD a diverticulum was seen.
Zenker's diverticulum, also known as pharyngeal pouch, is really a pseudodiverticulum, as it only contains mucosa and submucosa and does not involve all the layers of the esophageal. This pseudodiverticulum results from posterior herniation of esophageal mucosa into Killian's triangle, an area of least resistance situated above the upper esophageal sphincter (cricopharyngeal muscle) and below the inferior pharyngeal constrictor muscle.
Symptoms of Zenker’s diverticulum are dysphagia, and the pooling of food within the diverticulum, which can cause bad breath, frequent regurgitation and aspiration pneumonia.
Treatment consists of a surgical transcervical diverticulectomy without myotomy, diverticulopexy or endoscopic myotomy of the septum (i.e. longitudinal incision and dissection into the anterior septum). A myotomy can be accomplished using rigid or flexible endoscopes. Nowadays, most myotomies are performed by interventional endoscopists and ear nose and throat (ENT) specialists.
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