Esophageal diverticula: causes, symptoms, diagnosis, treatment

An esophageal diverticulum is a protrusion of the mucosa through the muscular layer of the esophagus. The condition may be asymptomatic or cause dysphagia and regurgitation. Diagnosis is by barium swallow; surgical treatment of esophageal diverticulum is rare.

A distinction is made between true and false diverticula of the esophagus. True ones are lined with normal mucous membrane, false ones are associated with an inflammatory or cicatricial process and are not lined with mucous membrane. By origin, a distinction is made between pulsion and traction diverticula. According to A.V. Sudakevich (1964), who examined 472 patients with diverticula, pulsion diverticula account for 39.8%, traction diverticula - 60.2%.

There are several types of esophageal diverticula, each with a different etiology. Zenker's (pharyngeal) diverticula are posterior protrusions of the mucosa or submucosa through the cricopharyngeal muscle, probably due to incoordination between pharyngeal propulsion and cricopharyngeal relaxation. Midesophageal (traction) diverticula are caused by traction due to inflammatory processes in the mediastinum or secondary to motility disorders. Epiphrenic diverticula are located above the diaphragm and are usually accompanied by motility disorders (achalasia, diffuse esophageal spasm).

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Esophageal diverticulum symptoms

When food enters a Zenker's diverticulum, regurgitation may occur when bending over or lying down. Pulmonary aspiration may occur during sleep. Rarely, the diverticular sac becomes large, causing dysphagia and a large, palpable mass in the neck. Traction and epiphrenic diverticula rarely cause specific symptoms despite the presence of an underlying disease.

True esophageal diverticula

True diverticula of the esophagus are most often found in the initial part of the esophagus, and are called Zenker's (or borderline) after the author who described them. In this part of the esophagus, diverticula are mainly of pulsion origin. In the rest of the esophagus, traction diverticula are more often observed, which subsequently, as they increase, can become pulsion. Zenker's diverticula form directly above the sphincter of the esophagus in the so-called Limer's triangular space, where the walls of the esophagus are less developed and are more susceptible to pressure from the inside (pulsion mechanism), especially with scars after damage to the underlying section, as well as with other diseases (foreign body entrapment, spasm, tumors, goiter, etc.) that impede the passage of food. In this case, peristaltic contraction of the overlying muscles creates increased pressure on the contents of the esophagus located above the stricture; this pressure stretches the wall of the esophagus at the point of least resistance, resulting in the creation of a diverticulum. Zenker's diverticula are usually located on the back wall of the esophagus, slightly to the side and to the left. Their size varies from a pea to a large apple or more. They communicate with the esophagus by a narrow slit-like or round passage, through which the diverticulum gradually fills with food masses, which increase it to a size that allows it to be detected during an external examination of the anterior surface of the neck.

The diverticulum enlarges gradually over months and years. Due to the stagnation of food masses in the mucous membrane lining the diverticulum, chronic inflammation develops, which can ulcerate in places, and the inflammatory process can spread to deeper layers of the diverticulum, going beyond its limits into deeper periesophageal tissues. Due to the inflammatory process going beyond the diverticulum, a cicatricial process develops in the surrounding tissues around its walls, on the neck and in the upper chest, leading to adhesions of the esophagus with the surrounding tissues. Since scars have the property of contracting during their development, the tissues and organs with which they are fused are stretched and deformed. In the esophagus, this process leads to the formation of traction diverticula.

Symptoms of Zenker's diverticulum

The initial symptoms of this diverticulum are so minor that patients cannot pinpoint when they began to notice difficulties in swallowing. A patient who sought help from a doctor for dysphagia recalls that “a long time ago,” in fact, 10-20 years ago, he began to notice more abundant salivation, a feeling of irritation and dryness in the throat, expectoration of a significant amount of sputum sometimes with an admixture of eaten food, a sore throat and a constant cough that intensifies after eating (pressure of the filled house on the laryngeal nerves), often ending in vomiting. Later, a feeling of obstruction appears when food passes through the esophagus, which forces the patient to slowly and carefully swallow well-chewed food in small portions. In the initial stages of development, the diverticulum, being small, fills with food during the first sips, after which it no longer interferes with the act of swallowing. In later stages, when it reaches a significant size, being outside the esophagus, but in close proximity to it, overflowing, it squeezes it, causing accentuated phenomena of dysphagia. Many patients begin to "choke", artificially induce vomiting and regurgitate food masses retained in the diverticulum. The diverticulum of the esophagus is emptied, and the patient again gets the opportunity to swallow until this sac-like expansion of the esophagus is filled again. However, nausea, vomiting and regurgitation do not always appear, and then the esophagus squeezed by the diverticulum does not pass a single sip, even liquid. Patients experience severe pain from the stretching of the esophagus over the squeezed part, they rush about, turn and bend their heads in different directions, trying to find the position in which the diverticulum can be emptied. In most cases, patients already know with what movements and in what position of the head it is possible to empty the diverticulum, if not completely, then at least partially. After emptying the diverticulum, patients feel significant relief, and the feeling of hunger returns to them, but seasoned with fear of a new repetition of the unpleasant episode. They dilute solid food with liquid and take it in small sips, between which they create "waiting intervals", making sure that the food lump has passed unhindered into the stomach.

The food remaining in the diverticulum becomes its permanent content, it stagnates, decomposes, as a result of which patients develop a foul odor from the mouth, and the entry of these putrefactive masses into the stomach and then into the intestines causes a number of dyspeptic disorders. If there is air and liquid in the diverticulum, the patient himself and those around him can hear the sounds of pouring and splashing in it when shaking the head and body.

A number of signs of the presence of a diverticulum arise from its mechanical impact on adjacent organs (trachea, cervical and brachial plexuses, recurrent nerve, cervical vessels), which in some cases can provoke dysfunctions of these organs and a number of pathognomonic symptoms. Thus, when the laryngeal nerves are compressed, dysphonia occurs, paresis of the intralaryngeal muscles, the form of which depends on the nerve experiencing pressure, when the trachea and large vessels are compressed, specific noises may occur, synchronous with the respiratory cycles and pulse.

The inflammatory process from the diverticulum spreads to adjacent anatomical structures, causing pain radiating to the neck, back of the head, behind the sternum, to the shoulder blade area, etc.

Patients complain of constant thirst, hunger; they lose weight. If appropriate radical measures are not taken, they die from exhaustion and cachexia. Fatal outcomes are also possible with diverticula complicated by secondary inflammatory processes in neighboring organs. Thus, according to Lyudin, 16-17% of patients with esophageal diverticula die from pneumonia, gangrene, lungs or other diseases associated with severe infectious processes that have spread from a perforated diverticulum. This is facilitated by a progressive immunodeficiency state of nutritional (alimentary) genesis (protein deficiency).

Diagnosis of Zenker's diverticulum

The diagnosis of Zenker's diverticulum is established on the basis of the clinical picture described above. The most important symptoms include periodic swelling on the anterior surface of the neck during meals and its disappearance during pressure; peculiar sounds of overflowing liquid after drinking water and other liquids; regurgitation of food just eaten, transient pain behind the sternum that disappears after regurgitation or vomiting, etc. When this diverticulum descends into the upper chest, percussion may reveal high tympanitis, suggesting a cavern (Leffler's symptom).

Probing of the esophagus is of great importance for diagnosing diverticula. It is difficult to diagnose small diverticula using this method, since their narrow outlet is masked in the folds of the mucous membrane. In the case of large diverticula, the probe almost always enters the diverticulum, resting against its bottom at a height of approximately 20 cm. At this point, it is possible to palpate the end of the probe through the skin on the anterior surface of the neck. However, a probe stuck in a diverticulum can be passed into the stomach during repeated attempts at this manipulation. In the same way, as V. Ya. Levit (1962) points out, it is sometimes possible to pass another, thinner probe into the stomach next to the probe located in the diverticulum, which is a valuable diagnostic technique indicating the presence of a diverticulum.

Esophagoscopy reveals a concentrically narrowing slit that opens with a deep breath, looking like a funnel into which the fibrogastroscope tube passes. The mucous membrane visible in the empty diverticulum appears pale, covered with thick mucus, stretched in places, folded in places, with separate areas of inflammation and even ulceration.

X-ray imaging (graphy) shows how the contrasting mass enters directly into the diverticulum, filling it. In this case, the diverticulum is visualized as a round or oval shadow with smooth edges. Uneven edges of the diverticulum indicate the fusion of its walls with the surrounding tissues.

Much less frequently, Zenker's diverticula are found between the sphincter and the cardia and in almost all cases after 40 years of age, more often in men. The size of these diverticula can vary from the size of a pea to the fist of an adult, but their shape can be round or pear-shaped. Diverticula above the diaphragm are called epiphrenic, in contrast to epibronchial, located at the level of the intersection of the esophagus with the left main bronchus. Symptoms of diverticula in this localization are revealed when they reach a significant size. Patients complain mainly of palpitations, lack of air, shortness of breath, a feeling of support in the epigastric region, which disappear immediately after vomiting. Complaints of dysphagia are either absent or not expressed, since only large saccular diverticula in these areas can press on the esophagus and make swallowing difficult.

The level of the diverticulum can be determined by repeated probing; usually the epibroichial diverticulum is located at a distance of 25-30 cm from the anterior teeth, and the epiphrenic diverticulum is at 40-42 cm. During gastroscopy, it can be difficult to find the opening connecting the esophagus with the diverticulum. Large diverticula in the lower part of the esophagus can be mistaken for its diffuse expansion. The basis for diagnosis is an X-ray examination, which almost always allows diagnosing a diverticulum, determining its shape, size and location.

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Treatment of true esophageal diverticula

Treatment of true esophageal diverticula is divided into symptomatic, non-operative and surgical. All measures should be aimed at eliminating compression of the esophagus by a filled diverticulum, which leads to expansion of the walls of the overlying segment, which is a secondary complication of the diverticulum and significantly increases the symptoms of dysphagia. Since the disease remains unnoticed at the early stages, the doctor sees patients with a significantly developed diverticulum with all its inherent clinical signs. First aid for a filled diverticulum consists of removing stagnant masses by washing it, but this procedure does not eliminate the disease, which steadily progresses and ultimately leads to severe complications. Non-surgical measures cannot break the vicious circle (filling of the diverticulum, its expansion, stagnation and decomposition of accumulated masses, inflammation of the mucous membrane, its ulceration, spread of infection to surrounding tissues, periesophagitis, diverticulum rupture, mediastinitis, etc.), therefore, in such cases, surgical treatment is indicated. In case of nutritional deficiencies and severe weakness of the patient (anemia, decreased immunity, metabolic disorders, etc.), preoperative preparation is carried out before the main surgical intervention (imposition of a gastrostomy to ensure complete high-energy nutrition rich in vitamins and proteins, administration of immunomodulatory and vitamin preparations, as well as food additives that normalize metabolism and other drugs, as indicated.

There are several methods of surgical removal of diverticula. Complete removal of the diverticulum was proposed by the German surgeon F. Kluge in the middle of the 19th century, and since then this method has been the most radical, leading to complete recovery. The following methods were subsequently proposed.

1. Girard's method is aimed at invaginating the isolated diverticulum into the esophagus without opening the lumen of the esophagus and suturing the esophageal walls above it. The method is applicable to small diverticula that do not interfere with the esophageal function of the esophagus.
2. The method of displacement proposed by Schmidt: the isolated sac is moved under the skin and fixed to the muscles of the pharynx. This is approximately the same method as that of N.A. Bogoraz (1874-1952), an outstanding Soviet surgeon, a graduate of the Military Medical Academy, one of the founders of reconstructive surgery, who sewed the isolated sac subcutaneously, moving it upward. Goldman separated the isolated and moved under the skin sac with a thermocauter after 9 days.
3. The most effective and reliable method is excision of the sac at its very neck, followed by the application of a two-layer suture to the wound of the esophagus.

Before the introduction of antibiotics into practice, postoperative mortality, according to foreign authors, was 8-10%. Currently, unfavorable outcomes in such surgical interventions are practically absent.

In the first third of the 20th century, surgical treatment of intrathoracic diverticula was performed very rarely due to the high risk of both the intervention itself and frequent intra- and postoperative complications. Currently, due to significant progress in the field of anesthesiology and resuscitation, these surgeries occur without significant negative consequences. Of the surgical methods, intussusception of the isolated diverticulum into the lumen of the esophagus was proposed, and in the case of a low location of the sac, anastomosis was created between the diverticulum and the stomach pulled up to the opening of the diaphragm. Postoperative mortality in the case of thoracic localization of the diverticulum was higher than in Zenker's diverticula, and therefore it was believed that small intrathoracic esophageal diverticula were not subject to treatment at all, and in the case of large ones, non-surgical treatment was indicated, including systematic washing of the diverticulum with weak antiseptic solutions and feeding the patient through a gastric tube. However, since the 1950s, The practice of treating patients with low-lying diverticula includes a surgical method using methods of radical excision or resection of the esophagus with the imposition of an esophagogastric anastomosis. Non-surgical methods are used only as means of preoperative preparation in emaciated patients, in the presence of peri- or esophagitis, etc.

False diverticula of the esophagus

False diverticula of the esophagus are most often associated with inflammatory processes occurring in the paraesophageal lymph nodes. The latter, undergoing cicatricial degeneration and wrinkling, exert a constant traction effect on the wall of the esophagus outward, causing its deformation with the formation of traction diverticula. In the wall of the apical part of such diverticula, the mucous membrane is replaced by scar tissue. Such diverticula are located on the anterior or lateral wall of the esophagus, mainly at the level of bifurcation. Communication with the esophagus is usually wide, longitudinal-oval, reaching 6-8 cm in diameter.

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Symptoms of false diverticula of the esophagus

False diverticula of the esophagus with a developed clinical picture appear after 30 years, when chronic mediastinal adenitis of various etiologies completes its development cycle (scarring and shrinkage of the paraesophageal lymph nodes). Symptoms are absent in most cases. The pain that arises may depend on the inflammatory process in the diverticulum wall or in the external lymph node.

Diagnosis of false diverticula of the esophagus

The diagnosis is established on the basis of probing, fibrogastroscopy and radiography. When probing, care should be taken due to the existing risk of perforation of the traction diverticulum, the wall of which is always thinned and easily damaged.

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Treatment of false diverticula of the esophagus

Treatment of false diverticula of the esophagus in the case of an unfinished regional inflammatory process is only non-surgical and should be aimed at eliminating this inflammatory process. In the case of a healed lesion, the treatment objective is to eliminate the factors that contribute to the transition of the traction diverticulum to a pulsion diverticulum, primarily to prevent or eliminate esophageal spasm and esophagitis. If a foreign body gets stuck or food masses are delayed in the diverticulum, they should be removed. Elimination of chronic inflammation of the mucous membrane of the diverticulum and esophagus is achieved by repeated rinsing with antiseptic and astringent solutions. If the diverticulum breaks through into adjacent organs, extremely dangerous complications arise that require urgent surgical intervention. Surgical treatment of intrathoracic diverticula of the esophagus is the responsibility of thoracic surgeons. For Zenker's diverticula, surgical interventions are available to ENT surgeons with experience in surgical interventions on the larynx and neck.

Diagnosis of esophageal diverticulum

All esophageal diverticula are diagnosed radiographically with a barium swallow.

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Treatment of esophageal diverticulum

Specific treatment is usually not required, but resection is sometimes necessary for large or symptomatic diverticula. Esophageal diverticula associated with motility disorders require treatment of the underlying disorder. For example, there are reports of a case where a cricopharyngeal myotomy was performed during resection of a Zenker diverticulum.