An esophageal diverticulum is an outward protrusion of the esophagus. They are divided into three groups. The following describes the clinical picture, course, diagnosis, treatment and prevention.
What is an esophageal diverticulum?
Esophageal diverticula are typically characterized by difficulty swallowing and unconscious regurgitation of food debris from the intestine. Esophageal diverticula are a rather rare condition. Most often, men of older age are affected. It results in an outward protrusion of the esophageal wall. Esophagus comes from the Greek and means “the food bearer” and thus stands for the esophagus. Diverticulum comes from Latin and means deviation or deviation. In this clinical picture, a distinction is made between “false” and “true” diverticula. If only a mucosal prolapse develops, only the mucosa bulges outward, this is called a false diverticulum. If, on the other hand, all layers of the esophageal wall are affected by the protrusion, physicians refer to this as a true diverticulum. Diverticula are localized and can vary in size. They develop at the physiological narrowing points of the esophagus, thus in the upper, middle and lower thirds.
Causes
Esophageal diverticula can occur during life or are congenital. They develop due to increased pressure in the hollow organ or the application of traction from the outside, causing the tissue to give way and a diverticulum to form. A distinction is made between pulsion diverticula and traction diverticula. Pulsion diverticula are manifested by excessive pressure in the esophagus and an existing weakness of the esophageal wall. There is a bulging of the mucosa, usually in the upper third of the esophagus. This type of diverticulum is named after the Dresden pathologist Friedrich Albert von Zenker. In addition to Zenker’s diverticulum, it is also called hypopharyngeal or cervical diverticulum. Pulsatile diverticula also include epiphrenal diverticula arising in the lower third. Traction diverticula arise from an external traction force. These often involve inflammatory lymph nodes present in adjacent tissues. The type of esophageal diverticula occur predominantly in the middle portion of the esophagus. They are also called epibronchial or parabronchial diverticula because of their proximity to the main bronchi.
Symptoms, complaints, and signs
The symptomatology of esophageal diverticula depends on the type and location of the bulges. For example, pulsatile diverticula cause more severe symptoms than traction diverticula. In the case of pulsatile diverticula, a distinction can be made between the symptoms of Zenker’s diverticulum and those of epiphrenic diverticula. Zenker’s diverticulum in the upper part of the esophagus initially begins with such complaints as a rough throat, a constant feeling of foreign bodies in the throat, and chronic throat clearing. Over time, the complaints increase. The bulge of the esophagus below the pharynx slowly becomes larger and causes increasingly severe swallowing difficulties, which are especially noticeable when eating solid food. A gurgling sound occurs when drinking. Since the food pulp is no longer transported further and accumulates in the bulge, there is permanent bad breath and constant belching. When lying down at night, food pulp can get into the oral cavity and from there to the outside. Thus, in the morning, leftover food is often discovered on the pillow. Epiphrenic diverticula, which occur in the lower part of the esophagus, produce less specific symptoms that may also indicate other diseases. For example, there is often reflux of stomach acid into the esophagus, which leads to severe heartburn and pain behind the breastbone. In addition to swallowing difficulties, food debris can also reach the oral cavity when lying down. The parabronchial traction diverticulum, on the other hand, is usually symptom-free. However, coughing may occur in the presence of inflammation.
Diagnosis and course
Zenker’s diverticulum occurs with a frequency of 70%. Symptoms develop rather insidiously over time. Affected individuals usually suffer from a rough throat, frequent throat clearing, and a foreign body sensation. However, there may also be difficulty swallowing solid food and a gurgling sound when ingesting liquids.Many patients also suffer from bad breath and regurgitate food debris that remains in the diverticulum. Epiphrenal diverticula cause rather nonspecific symptoms, such as pain in the upper abdomen, nighttime pressure pain behind the sternum, and difficulty swallowing. In parabronchial diverticulum, symptoms rarely occur. Diverticula are often discovered incidentally during x-ray examinations. All three types can cause inflammation of the esophagus and reflux disease due to food remaining in the diverticula. Furthermore, it can lead to so-called regurgitations, whereby remaining food particles are pushed open, especially in a lying position. This creates a risk of aspiration, as the food particles can be inhaled. If a diverticulum is suspected, an X-ray examination is ordered. Using a barium sulfate solution, any remaining solution in the diverticulum can be detected under x-ray vision. An esophageal endoscopy is usually performed only to rule out tumors.
Complications
Esophageal diverticula have a very good prognosis after treatment. However, serious complications can occur if left untreated. The greatest risks for a complicated course are with the so-called Zenker diverticulum. This is a pulsatile diverticulum in the upper part of the esophagus. These diverticula must be surgically removed, because otherwise sometimes life-threatening complications can develop. For example, food debris remaining in the diverticulum irritates the esophagus. Inflammation occurs, which can even lead to esophageal bleeding. In some cases, there is even a rupture of the esophagus. Particularly at night when lying down, reflux of esophageal debris from the diverticulum can occur. When inhaled, these enter the trachea and from there also the lungs. There is a risk of suffocation. At the same time, the esophageal debris can cause pneumonia or lung abscesses. Epiphrenic diverticula, which occur at the lower end of the esophagus, also often lead to inflammation of the esophagus. Furthermore, persistent gastroesophageal reflux can develop, causing chronic heartburn and increasing the risk of esophageal cancer. To a lesser extent, esophageal debris can also enter the pharynx and trachea, causing choking or pneumonia. Parabronchial diverticula are located in the middle of the esophagus and usually do not cause symptoms. In very rare cases, however, connections (fistulas) to the trachea can form, so that the esophageal debris can also enter the airways here and lead to the corresponding life-threatening complications.
When should you go to the doctor?
An esophageal diverticulum may be congenital or develop during life. In the case of a congenital disorder, the first health irregularities are usually noticed within the first few days after birth. If irregularities in feeding become apparent, consultation with a physician is required. If the disease develops during life, there is usually an increase in symptoms over a longer period of time. Problems with the swallowing act, loss of appetite, and a refusal to eat are among the health impairments that occur and need to be investigated. Changes in speech, pain or a general feeling of discomfort should be presented to a physician. If the usual foods can no longer be transported through the pharynx into the esophagus without discomfort, a visit to the doctor is necessary. A decrease in body weight as well as the feeling of internal dryness must be investigated and treated. If left untreated, serious health consequences may result, as dehydration may occur if fluid intake is denied. This is a life-threatening condition requiring immediate medical attention. Heartburn, chest pain, or irregularity in coughing should be presented to a physician. In rare cases, there is also interference with breathing or a feeling of tightness.
Treatment and therapy
Treatment of Zenker’s diverticulum as well as epiphrenal diverticulum is surgical. This involves exposing the esophagus and ablating the diverticulum present. This treatment is called diverticulopexy. In the case of a Zenker diverticulum, there is also the option of minimally invasive removal through the oral cavity.Parabronchial diverticula are only surgically removed if absolutely necessary. In patients suffering from an epiphrenal diverticulum, the first attempt is to bring about symptom relief by eating small meals and avoiding large amounts of alcoholic, fatty and acidic foods and chocolates. Medications for reflux disease that may be occurring may also reduce symptoms.
Prevention
Prevention of oesophageal diverticulum is not explicitly possible. However, a balanced diet and small portions spare the digestive tract, thereby reducing the risk of developing diverticulum.
What you can do yourself
If the doctor has prescribed conservative therapy, its success requires the active participation of the patient. To reduce the reflux of gastric juice into the esophagus, it is necessary to adjust eating habits. Those who have been eating the usual three large meals should initially switch to five to six smaller meals. In addition, it is important to eat the right things and avoid counterproductive foods. Harmful are all foods that strongly stimulate gastric juice production. These include, in the first place, very fatty foods. In particular, red meat, sausage, fatty cheese, butter and cream should be avoided. Most sufferers also react to sugar and desserts with increased gastric juice production. In this case, such foods should also be consumed only as an exception. In addition, tea is usually more digestible than coffee. Those who do not want to do without their breakfast coffee can switch to cereal-based products. Spelt coffee is particularly tasty and easily digestible. In addition, alcohol, especially in the form of highly acidic or high-proof drinks, should be avoided. The consumption of acidic foods also usually has an unfavorable effect on the esophageal diverticulum. In contrast, whole-grain products, vegetables and non-acidic fruits, especially bananas, are recommended. If reflux of gastric juice or food residues occurs especially at night, an upright sleeping posture can provide additional relief.
