Zenker Diverticulum

A 72-year-old man was evaluated for worsening dysphagia and weight loss. The dysphagia had been intermittent for 20 years, but in the past year it had begun to occur daily. He regurgitated food after every meal, often many hours after ingestion.

A barium swallow examination demonstrated a large (3 3 7-cm) Zenker diverticulum that originated from the posterior wall of the esophagus at the C5-C6 level (arrow). Esophagogastroduodenoscopy confirmed this finding and ruled out other lesions, reports Love Dalal, MD, of Bakersfield, Calif. The patient subsequently underwent a cricopharygomyotomy and plexy of the diverticulum. He is now able to swallow without difficulty and has regained weight.

Zenker diverticula are usually found in older adults. Most patients present after the age of 60 (often after age 75) and have had symptoms for weeks to years. The disorder is more common in men than in women. The estimated incidence in one study was 2 per 100,000 a year.¹ However, the true incidence may be difficult to evaluate, since many patients have minimal symptoms and may not seek medical attention.

A Zenker diverticulum consists of an outpouching of the mucosa through the Killian triangle, an area of muscular weakness between the oblique fibers of the lower inferior constrictor and the transverse fibers of the cricopharyngeus. Patients may have a persistent or intermittent sensation of sticking in the throat, transient dysphagia (particularly with solid foods), and intermittent cough. Severe symptoms develop as the diverticulum enlarges; these may include aggravation of dysphagia, regurgitation of food (ingested several hours earlier), halitosis, voice change, aspiration pneumonia, and weight loss. Small Zenker diverticula may be asymptomatic.

Barium swallow--the diagnostic procedure of choice for Zenker diverticulum--characteristically demonstrates a herniated sac with a slender neck that typically originates just proximal to the cricopharyngeus. When the diverticulum enlarges, it can compress the esophagus and cause dysphagia. Endoscopy can exclude other pathology, such as malignancy; however, it should be performed with extreme care in these patients to avoid perforation of the diverticulum.

Zenker diverticula can be treated with open surgery or an endoscopic approach. The surgical options are transcervical cricopharygomyotomy with resection of the diverticulum (diverticulotomy) and invagination of the diverticulum (diverticuloplexy).² Endoscopic approaches may replace conventional surgery, because they are minimally invasive and have similar results. The endoscopic methods include a staple-assisted approach (esophagodiverticulostomy)³ and an approach using a flexible endoscope and a soft diverticuloscope.⁴ Symptoms may recur if a myotomy has been incomplete or if there is apposition of the cut muscle margins. This is more likely in patients with wide diverticula.