Zenker's Diverticulum

Zenker's diverticulum (ZD) refers to a muscular pouch formed at the lower end of the throat and the beginning of the esophagus (food pipe). The pouch is formed because a muscle called cricopharyngeal fails to relax during swallowing. The overtightening of the cricopharyngeal muscle provokes the normal anatomy of the throat to distort, causing outpouching at the region of the lower throat and upper esophagus. As a result, the food accumulates and gets stuck in this pouch, leading to subsequent obstruction. Untreated cases can lead to severe compaction of food and saliva. 

The exact cause is unknown as Zenker’s diverticulum is a very rare condition. Lesser than 0.01% of the population progress in developing this pouch. It is believed to result from the extreme pressure on the esophagus resulting in the malfunctioning of the cricopharyngeal muscle. Pressure can also cause the tissue of the esophagus to split apart, leading to the formation of Zenker’s diverticulum. 

Some common risk factors of the Zenker's diverticulum (ZD) include: 

·         Old age (seventh and eighth decade of life)

·         Male gender

·         Gastroesophageal reflux disease (GERD)

·         Pre-existing hiatal hernia

·         Oesophageal motility disorder

·         Esophagitis

·         Neurological disorders like a stroke

The prevalence of Zenker diverticulum in the United States span from 0.01 to 0.11% of the population.  

The most common symptom of Zenker’s diverticulum is difficulty swallowing (dysphagia) solids and liquids. As food is frequently stuck in the pouch, many people are inclined to alter their diets to include soft foods or things that are easier to swallow. It may also be seen that a person suffering from Zenker’s diverticulum eats less because of difficulty in swallowing.

Some other common symptoms include:

·         Weight loss

·         Halitosis ( Bad breath) due to food being stuck in the pouch

·         A persistent cough, especially at night time

·         Regurgitation of undigested food

·         Hoarse voice or a change in voice

·         Aspiration that can lead to pneumonia

·         Gurgling noises

·         Feeling like something is stuck in the throat

After thorough history and examination, your doctor may advise the following tests to confirm the diagnosis;

Barium swallow: In this procedure, a person is asked to swallow a contrast barium drink, and images are taken via x-rays to visualize the process of swallowing and the defects present. It is also called an esophagogram. If a video accompanies the test, it is known as a barium videofluoroscopy.

Upper endoscopy: In this test, a flexible tube with a camera is inserted through your mouth to visualize the inside of the esophagus, stomach, and duodenum. You may be sedated during this test. It enables the doctor to assess the size of the pouch and rule out other possible causes of dysphagia like cancer or strictures.

Manometry: This test is used to measure the pressure in the muscles of the esophagus made during the contraction and relaxation of the muscles. 

Some other disorders that present like Zenker's diverticulum, need to be ruled out while making a diagnosis;

·         Plummer-Vinson syndrome

·         Reflux esophagitis

·         Oesophageal carcinoma 

·         Systemic sclerosis

·         Achalasia

·         Psuedoachalasia

·         Chagas disease 

·         Oesophageal candidiasis 

·         Pharyngitis 

·         Stroke

Treatment for symptomatic Zenker's diverticulum includes surgical or endoscopic procedures.

Surgical methods used for ZD include:

·         The surgical approach involves a neck incision in the cricopharyngeal muscle called cp myotomy (diverticulectomy), with or without the intervention of pouch (inversion, diverticula, or diverticulectomy). 

·         The endoscopic approach uses rigid or flexible endoscopes, which only involve diverticulectomy. In this, the septum between the oesophageal lumen, the diverticulum, and the CP muscle is cut to build up a single channel for drainage. 

Certain asymptomatic mild forms of Zenker’s diverticulum do not require treatment. Whereas moderate to severe forms of Zenker’s diverticulum typically involves surgical treatment. The long-term prognosis for Zenker’s diverticulum is typically satisfying. Most people experience considerable improvement in symptoms with the treatment. 

Due to retained solid foods, patients can switch to adopting a pureed (semi-liquid) or full-liquid diet. In the care of a dietician, meals can be made to be delicious and the ones that provide adequate caloric intake to carry on a healthy weight and a better quality of life.

Patients with dietary changes and altered meal plans are at increased risk of aspiration and pneumonia. Therefore, maintaining oral hygiene and adhering to instructions given by your doctor is necessary because if fewer bacteria are present in the mouth, the chances of lung infection and sepsis are reduced remarkably in case of aspiration incidents.

Slow chewing is also recommended, so the food does not stick up in the diverticulum.

Our clinical experts continually monitor the health and medical content posted on CURA4U, and we update our blogs and articles when new information becomes available. Last reviewed by Dr.Saad Zia on May 04, 2023.

References

https://www.ncbi.nlm.nih.gov/books/NBK499996/

https://www.pennmedicine.org/for-patients-and-visitors/patient-information/conditions-treated-a-to-z/zenkers-diverticulum#:~:text=Zenker's%20diverticulum%20develops%20when%20the,it%20can%20cause%20an%20obstruction.