Esophageal diverticula: causes, symptoms, diagnosis, treatment

Diverticulum of the esophagus is a protrusion of the mucosa through the muscular layer of the esophagus. The disease can be asymptomatic or cause dysphagia and regurgitation. The diagnosis is established radiologically with a sip of barium; surgical treatment of the esophageal diverticulum is rarely used.

There are true and false diverticula of the esophagus. True - are lined with normal mucous membrane, false - are associated with inflammatory or scarring process and are not lined with mucous membrane. By origin, pulsion and traction diverticula are distinguished. According to A.Sudakevich (1964), who examined 472 patients with diverticula, 39.8% of the pulsed patients and 60.2% of the traction ones were involved in the pulsion.

There are several types of esophageal diverticula, each with a different etiology. Zenker's (pharyngeal) diverticula are a protrusion of the mucosa or submucosal membrane posteriorly through the cryo-pharyngeal muscle, probably due to the lack of coordination between pharyngeal propulsation and cryopharyngeal relaxation. Mid-esophageal (tractional) diverticula are caused by traction due to inflammatory processes in the mediastinum or secondary due to motor disruption. Epiphrenic diverticula are located above the diaphragm and are usually accompanied by impaired motor activity (achalasia, diffuse spasm of the esophagus).

[1], [2]

Symptoms of esophageal diverticulum

When food gets into the Tseker diverticulum, there may be a regurgitation with the body tilted or lying down. During a dream, pulmonary aspiration may occur. Rarely does the diverticular bag become large, causing dysphagia and the appearance of a voluminous, palpable formation on the neck. Traction and epiphrenic diverticula are rarely manifested by specific symptoms, despite the presence of the underlying disease.

True diverticula of the esophagus

The true diverticula of the esophagus are more often found in the initial part of the esophagus, named according to the author who described them, the Tseker (or borderline). In this part of the esophagus, diverticula are mainly of pulsed origin. In the rest of the esophagus, tractional diverticula are more often observed, which in the future, as they increase, can become pulsatile. Zenker diverticula are formed directly above the esophagus in the so-called Lamer triangular space, where the walls of the esophagus are less developed and more susceptible to pressure from the inside (the pulsing mechanism), especially in the scars after injuries of the underlying section, as well as in other diseases (foreign body stasis, spasm, tumors , goiter, etc.), preventing the passage of food. In this case, peristaltic contraction of the overlying muscles creates an increased pressure on the contents of the esophagus, which is above the stricture; this pressure stretches the wall of the esophagus in the place of least resistance, resulting in a diverticulum. Zenker's diverticula are usually located on the back wall of the esophagus, somewhat laterally and to the left. Their size ranges from a pea to a large apple and more. They communicate with the esophagus by a narrow slit-like or round passage, through which the diverticulum gradually replenishes with food masses, which increase it to a size that allows it to be detected with an external examination of the anterior surface of the neck.

The increase in diverticulum occurs gradually over months and years. In connection with the stagnation of food masses in the mucous membrane lining the diverticulum, chronic inflammation develops, which can ulcerate in places, and the inflammatory process spread to the deeper layers of the diverticulum, extending beyond it into deeper cavernosophageal tissues. Due to the release of the inflammatory process, a scar process develops outside the diverticulum in the surrounding tissues around its walls, on the neck and in the upper chest, leading to fusion of the esophagus with surrounding tissues. Since scars in the process of their development have the property of contracting, the tissues and organs with which they are joined are stretched and deformed. In the esophagus, this process leads to the formation of tractional diverticula.

Symptoms of the Center diverticulum

The initial symptoms of the appearance of this diverticulum are so insignificant that the patients can not accurately indicate when they began to notice the difficulty of swallowing. The patient, who turned to a doctor for dysphagia for help, remembers that already "very long time," in fact, 10-20 years ago, began to notice a more abundant secretion of saliva, a feeling of irritation and dryness in the throat, expectoration of a significant amount of sputum, sometimes with an admixture of food eaten , perspiration in the larynx and a persistent cough that increases after eating (pressure filled home with the guttural nerves), often resulting in vomiting. Later, there is a sense of obstruction in the passage of food through the esophagus, which causes the patient to slowly and gently ingest a well-chewed food in small portions. In the initial stages of development, the diverticulum, being small, is filled with food at the first sips, after which it no longer violates the swallowing act. In later stages, when it reaches a considerable value, being outside the esophagus, but in close proximity to it, overflowing, squeezes it, causing accented phenomena of dysphagia. Many patients begin to "choke", artificially induce vomiting and regurgitate the food masses that have lingered in the diverticulum. The diverticulum of the esophagus is then emptied, and the patient again has the opportunity to swallow until this sack-shaped expansion of the esophagus is again filled. However, nausea, vomiting and regurgitation do not always appear, and then the esophagus, squeezed by the diverticulum, does not pass more than one sip even of the liquid. Patients experience severe pain from stretching the esophagus over the squeezed part, they rush, turn and bend the head in different directions, trying to find a position where the diverticulum can empty. In most cases, patients already know at what movements and at what position of the head it is possible to empty the diverticulum, if not completely, at least partially. After the diverticulum has been emptied, the patients feel considerable relief, and the feeling of hunger returns again, but is seasoned with fear before a new repetition of an unpleasant episode. Dense food, they dilute the liquid and take in small sips, between which create "waiting intervals", making sure that the food lump went unchecked into the stomach.

The food remaining in the diverticulum becomes its constant content, it stagnates, decomposes, resulting in a bad smell from the mouth, and the ingress of these putrefactive masses into the stomach and further into the intestines causes a number of dyspeptic disorders. If there is air and fluid in the diverticulum, the patient and others can hear the transfusion and splash noise in it when the head and trunk are shaking.

A number of signs of the presence of a diverticulum arise when it is mechanically influenced by neighboring organs (trachea, cervical and brachial plexus, recurrent nerve, cervical vessels), which in some cases can provoke disorders in the functions of these organs and a number of pathogens. Thus, when the laryngeal nerves are compressed, dysphonia phenomena arise, the paresis of the inner-throat muscles, the shape of which depends on the pressure nerve, when the trachea and large vessels are compressed, specific noises, synchronous with respiratory cycles and pulse, may appear.

The inflammatory process from the diverticulum spreads to neighboring anatomical formations, pains appear, radiating to the neck, back of the neck, behind the sternum, into the scapula area, etc.

Patients complain of constant thirst, hunger; they lose weight. In the absence of appropriate radical measures, they perish from the decline of forces and cachexia. Deadly outcomes are 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 the perforated diverticula. Promotes this progressive immune deficiency state of nutritional (alimentary) genesis (protein deficiency).

Diagnosis of the Center diverticulum

Diagnosis of the Center diverticulum is established on the basis of the above clinical picture. Of the most important symptoms should be noted the periodic appearance of swelling on the front surface of the neck during food intake and its disappearance during the pressing; peculiar noise of the iridescent liquid after drinking water and other liquids; regurgitation of freshly eaten food, transient pains behind the breastbone, disappearing after regurgitation or vomiting, etc. When lowering this diverticulum to the upper chest, percussion can reveal a high tympanitis suggestive of a cavern (Leffler's symptom).

Esophageal sounding is important for the diagnosis of diverticula. Small diverticula diagnosed with this method is difficult, since their narrow outlet hole is masked in the folds of the mucosa. With large diverticula, the probe almost always gets into the diverticulum, resting on its bottom approximately at a height of 20 cm. At this point it is possible to probe through the skin on the front surface of the neck the tip of the probe. However, the probe, stuck in the diverticulum, can be carried to the stomach with repeated attempts at this manipulation. Similarly, as V.Ya.Levit (1962) points out, sometimes, next to the probe located in the diverticulum, another, more delicate probe into the stomach will be carried out, which is a valuable diagnostic device indicating the presence of a diverticulum.

When esophagoscopy is visible concentrically narrowing the gap, which opens with a deep breath, which looks like a funnel, where the tube of the fibrogastroscope passes. Visible in an empty diverticulum, the mucous membrane appears pale, covered with thick mucus, sometimes stretched, sometimes folded, with separate areas of inflammation and even ulceration.

With fluoroscopy (graphy), you can see how the contrasting mass falls directly into the diverticulum, filling it. In this case, the diverticulum is visualized as a round or oval shadow with even edges. The unevenness of the edges of the diverticulum testifies to the fusion of its walls with surrounding tissues.

Significantly less often, Center diverticula are found between pulp and cardia and almost in all cases after 40 years, more often in men. The size of these diverticula can vary from the size of a pea to an adult's fist, but they may be round or pear-shaped. Diverticula above the diaphragm are called epiphrenic, unlike epibronchial ones, located at the level of the esophagus cross with the left main bronchus. Symptoms of diverticula of this localization are revealed when they reach considerable sizes. Patients complain mainly about palpitation, lack of air, dyspnea, a feeling of propping up in the epigastric region, disappearing immediately after vomiting. Complaints about dysphagia are either absent or not expressed, since only large sack-shaped diverticula in these parts can press on the esophagus and make it difficult to swallow.

Determine the level of the diverticulum can be by repeated sounding; usually epibroichial diverticulum is located at a distance of 25-30 cm from the front teeth, and epiphrenic - 40-42 cm. With gastroscopy it can be difficult to find a hole connecting the esophagus with the diverticulum. Large diverticula in the lower part of the esophagus can be taken as a diffusive extension of it. The basis of diagnosis is an X-ray study, with which it is almost always possible to diagnose a diverticulum, determine its shape, size and location.

[3]

Treatment of true esophageal diverticula

Treatment of the true diverticulum of the esophagus is divided into symptomatic, nonoperative and surgical. All measures should be aimed at eliminating the squeezing of the esophagus with a filled diverticulum, which leads to the expansion of the walls of the overlying segment, which is a secondary complication of the diverticulum and significantly increases the dysphagia phenomenon. Since in the early stages of the disease the disease goes unnoticed, patients with a significantly developed diverticulum with all the clinical signs that are inherent in it fall into the doctor's field of vision. The first help with a filled diverticulum is to remove stagnant masses by washing it, but this procedure does not eliminate the disease, which is steadily progressing and eventually leads to serious complications. Non-operative measures can not break the created vicious circle (the filling of the diverticulum, its expansion, stagnation and decomposition of accumulated masses, inflammation of the mucous membrane, its ulceration, the spread of infection in surrounding tissues, pereezophagitis, diverticulum breakthrough, mediastinitis, etc.); cases of surgical treatment. With the decline in nutrition and severe weakness of the patient (anemia, decreased immunity, metabolic disorders, etc.) before the main surgical intervention, preoperative preparation is carried out (application of a gastrostomy to ensure high-energy, vitamin-rich and protein-rich nutrition, administration of immunomodulating and vitamin preparations , as well as normalizing the metabolism of food additives and other medicines, according to the indications.

There are several ways of surgical removal of diverticula. The complete removal of the diverticulum was suggested by the German surgeon F. Kliige as early as the middle of the 19th century, and since then this method is the most radical, leading to complete recovery. Subsequently, the following methods were proposed.

1. Girard's method is aimed at preventing the secreted diverticulum from opening into the esophagus without opening the lumen of the esophagus and sewing over the walls of the esophagus. The method is applicable for small diverticula that do not interfere with esophageal esophageal function.
2. The method of displacement proposed by Schmidt: the allocated bag is moved under the skin and fixed to the muscles of the pharynx. The same way is about the method of NA Bogoraz (1874-1952) - an outstanding Soviet surgeon, graduate of the Military Medical Academy, one of the founders of reconstructive surgery, who sewed the saddle bag subcutaneously, moving it upward. Goldman separated the thermocouter isolated and moved under the skin bag after 9 days.
3. The most effective and reliable way of excising the bag at its neck and then applying a two-story seam to the esophagus wound.

Before the introduction of antibiotics, postoperative mortality, according to foreign authors, was 8-10%. Currently, there is practically no adverse outcome in such surgical interventions.

In the first third of the XX century. Surgical treatment with diverticula for intrathoracic localization was very rare in view of the great danger both of the intervention itself and of frequent intra- and postoperative complications. Currently, due to significant progress in the field of anesthesiology and resuscitation, these surgical interventions occur without significant adverse effects. Operative methods suggested the invagination of the isolated diverticulum into the lumen of the esophagus, and with a low bag location, an anastomosis between the diverticulum and the stomach, pulled up to the aperture of the diaphragm. Postoperative lethality with thoracic localization of the diverticulum was higher than with the diverticulum of the Centurion, and therefore it was believed that small intrathoracic diverticula of the esophagus were not treated at all, and for large ones, nonoperative treatment was indicated, including systematic washing of the diverticulum with weak antiseptic solutions and feeding the patient through the gastric tube. However, since the 50s of the XX century. In the practice of treating patients with low-lying diverticula is a surgical method with the use of methods of radical excision or resection of the esophagus with the imposition of esophageal-gastric anastomosis. Non-operative methods are used only as a means of preoperative preparation in depleted patients, with peri-or esophagitis, and so on.

False esophageal diverticula

False diverticula of the esophagus are most often associated with inflammatory processes that occur in the esophagus lymph nodes. The latter, undergoing cicatricial degeneration and wrinkling, exert a constant traction on the esophagus wall from the outside, causing it to deform with the formation of traction diverticula. In the wall of the apical part of such diverticula, the mucous membrane is replaced by a scar tissue. There are such diverticula on the anterior or lateral wall of the esophagus, mainly at the level of bifurcation. The communication with the esophagus is usually wide, longitudinal-oval, reaching up to 6-8 cm in diameter.

[4], [5]

Symptoms of false esophageal diverticula

False diverticula of the esophagus with a developed clinical picture appear after 30 years, when the chronic mediastinal adenitis of different etiology completes its development cycle (scarring and wrinkling of the esophagus lymph nodes). Symptoms in most cases are absent. The arising pains can depend on the inflammatory process in the wall of the diverticulum or in the outside of the LU.

Diagnosis of false esophageal diverticula

Diagnosis is established on the basis of sounding, fibrogastroscopy and radiography. When probing, care should be taken because of the existing danger of perforation of the tractional diverticula, the wall of which is always thinned and easily damaged.

[6], [7]

Treatment of false esophageal diverticula

Treatment of false esophageal diverticula in a regional inflammatory process that has not ended is only inoperative and should be aimed at eliminating this inflammatory process. With a healed out focus, the task of treatment is to eliminate the factors contributing to the transition of the diverticulum to pulsion, in the first place to prevent or eliminate spasm of the esophagus and the phenomena of esophagitis. If a foreign body gets stuck or the food masses in the diverticulum are delayed, they should be removed. Elimination of the phenomena of chronic inflammation of the mucous membrane of the diverticulum and esophagus is achieved by repeated washing with antiseptic and astringent solutions. When a diverticulum breaks into neighboring organs, extremely dangerous complications arise that require urgent surgical intervention. Surgical treatment for intrathoracic diverticula of the esophagus is in the competence of thoracic surgeons. With Center diverticula, surgical interventions are available to ENT surgeons who have experience of surgical interventions on the larynx and neck.

Diagnosis of esophageal diverticulum

All diverticula of the esophagus are diagnosed radiologically with a sip of barium.

[8], [9], [10], [11]

Treatment of esophageal diverticulum

Specific treatment is usually not required, but with large or symptomatic diverticula sometimes their resection is necessary. Esophageal diverticula associated with motor disorders require treatment of the underlying disease. For example, there are reports of a cryopharyngeal myotomy when resection of a Zenker diverticulum.