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Thread: Zencker's Diverticulum Pictures - Esophagus Atlas

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    Default Zencker's Diverticulum Pictures - Esophagus Atlas

    Overview
    Zenker diverticulum, a pulsion diverticulum of the hypopharynx, is a rare lesion that occurs in elderly populations. The condition results in a classic presentation of symptoms, with complications that include aspiration and pneumonia, and is managed by endoscopic and surgical repair. (See the image below.)

    Zenker diverticula are lined with stratified squamous epithelium with a thin lamina propria. No muscular layer exists. Fibrosis surrounding the diverticulum is common.

    Pathophysiology
    The pathologic process in Zenker diverticulum involves herniation of the esophageal mucosa posteriorly between the cricopharyngeus (CP) muscle and the inferior pharyngeal constrictor muscles. Therefore, by strict definition, a Zenker diverticulum is a false diverticulum. The retention of food elements and secretions within the lesion’s pouch frequently leads to halitosis, regurgitation, aspiration, and dysphagia in patients.

    Although Zenker proposed that a pulsion mechanism affects the pharyngeal mucosa above the CP muscle, no consensus exists regarding a unifying concept of the cause of Zenker diverticula. The specific abnormality of the CP muscle has not been elucidated. Hypothetical abnormalities include the following:

    • Abnormal timing of deglutition resulting in closure of the CP muscle when ideally it should be opening
    • Incomplete CP muscle relaxation
    • Elevated resting tone of the entire upper esophageal sphincter (UES)
    • Loss of CP muscle elasticity
    • CP muscle myopathy or denervation atrophy
    • Central nervous system (CNS) injury with a focal spastic CP muscle
    • CP muscle spasm in response to gastroesophageal reflux disease (GERD)



    Studies to investigate the mechanism are scant. Cook histologically examined the CP muscle obtained at the time of diverticulectomy and found abundant fibrosis within the muscle. Whether this finding is a cause or a result of Zenker diverticulum is uncertain.
    Zencker's Diverticulum Pictures Esophagus Atlas attachment.php?s=7bfca7d25beb9fc35a87c3196724fad2&attachmentid=2711&d=1443371860

    Kern determined that older individuals exhibit less anterior excursion of the larynx and hyoid with deglutition than younger subjects, resulting in higher hypopharyngeal intrabolus pressures in older subjects. Whether this leads to Zenker diverticula over time is speculative. Van Overbeek suggested an anthropometric explanation. He felt individuals with longer necks had a larger Killian triangle, which predisposed them to formation of Zenker diverticulum.

    It is hypothesized that abnormal muscle activity in the cricopharyngeus results in a discoordination of the swallowing mechanism, which, when coupled with increased intraluminal pressure on the mucosa of the pharynx, results in the slow, progressive distention of the mucosa. As the weakest portion of this area is located posteriorly, this becomes the location of the pulsion diverticulum formation.

    Zenker diverticula extend into the left neck 90% of the time. This is likely due to the slight convexity of the cervical esophagus to the left side and to the more laterally positioned carotid artery on the left side, creating a potential space for the sac.

    Pressure measurements
    Esophageal manometry has been used to elucidate the pathophysiology of the upper esophagus, which is responsible for the diverticular formation. However, upper esophageal manometry is technically difficult to perform. Results are confounded by the asymmetry of the upper esophageal sphincter. Pressures can be very high, but they last for only a fraction of a second, resulting in difficulty obtaining equipment sensitive enough to demonstrate these pressures accurately.

    To further confound the problem, the process of obtaining measurements stimulates the swallowing reflex, resulting in the catheter being displaced and the data lost. Because of these limitations, very few studies have been performed to describe the manometric aspects of Zenker diverticulum. Manometry is certainly not useful in routine patient evaluation.
    Zencker's Diverticulum Pictures Esophagus Atlas attachment.php?s=7bfca7d25beb9fc35a87c3196724fad2&attachmentid=2712&d=1443371881

    The studies that have been performed show upper esophageal sphincter pressures that can be either normal or decreased. Some patients have abnormal premature relaxation and contractions of the upper esophageal sphincter, while others have pharyngeal contractions against a closed sphincter

    Etiology
    A complete understanding of the etiology of Zenker diverticulum formation is not available. Further studies focused on the function of the cricopharyngeus (CP) muscle are likely to be fruitful.

    Zenker diverticula occur in a muscular dehiscence that is present most commonly between the oblique muscle fibers of the inferior constrictor muscle and the transverse fibers of the CP muscle. This area is known as the Killian triangle. Other areas of muscular dehiscence occur between the oblique and transverse fibers of the CP muscle (ie, Killian-Jamieson area) and between the CP muscle and the esophageal muscles (ie, Laimer triangle). More inferiorly positioned Zenker diverticula may occur in one of these latter sites. (See the image below.)

    Occurrence in the United States
    The prevalence of Zenker diverticulum in the United States ranges from 0.01-0.11% of the population.[9] It is more common in males and in the elderly, with a peak incidence in the seventh to ninth decades.

    International occurrence
    Zenker diverticula occur more commonly in certain parts of the world. They are observed most often in northern European countries and in countries whose population has a northern European heritage (eg, United States, Canada, Australia). Zenker diverticulum is rarely observed in Japan and Indonesia. The prevalence in high-risk countries is 2 cases per 100,000 people. It has a male-to-female ratio of 1.5:1 and is observed almost exclusively in older individuals.

    History and Physical Examination
    The history strongly suggests the diagnosis of Zenker diverticulum. The combination of the following symptoms is nearly pathognomonic for the condition:
    Zencker's Diverticulum Pictures Esophagus Atlas attachment.php?s=7bfca7d25beb9fc35a87c3196724fad2&attachmentid=2713&d=1443371893

    • Dysphagia - Most patients (98%) present with some degree of dysphagia
    • Regurgitation of undigested food hours after eating
    • Sensation of food sticking in the throat
    • Special maneuvers to dislodge food
    • Coughing after eating
    • Aspiration of organic material
    • Unexplained weight loss
    • Fetor ex ore (halitosis)
    • Borborygmi in the neck


    Symptoms may last from months to years. The most common life-threatening complication in patients with a Zenker diverticulum is aspiration. Other complications include massive bleeding from the mucosa or from fistulization into a major vessel, esophageal obstruction, and fistulization into the trachea. Coexistent hiatal hernia, esophageal spasm, achalasia, and esophagogastroduodenal ulceration are common. Although the diverticulum can reach sizes of 15 cm or more, it is rarely palpable.

    Squamous cell carcinoma (SCC) within a Zenker diverticulum is extremely rare, occurring in 0.3% of Zenker diverticula worldwide. A Mayo Clinic review suggests an incidence of 0.48% in the United States. Approximately 50 cases of invasive SCC and carcinoma in situ are reported in the literature. This possibility should be considered when evaluating patients with cervical metastatic SCC with an unknown primary cancer

    Barium Swallow With Videofluoroscopy
    The criterion standard of confirmatory evaluations is the barium swallow with videofluoroscopy. This study provides information about the size, location, and character of the mucosal lining of the Zenker diverticulum, as depicted in the image below. Certain radiographic features of the diverticulum neck may predict the likelihood of success of the endoscopic stapling approach
    Zencker's Diverticulum Pictures Esophagus Atlas attachment.php?s=7bfca7d25beb9fc35a87c3196724fad2&attachmentid=2714&d=1443371908

    Patients with symptomatic disease usually have a posterior midline pouch greater than 2 cm in diameter arising just above the cricopharyngeus (CP) muscle. No other study is required if no other abnormality is present (See the image below.)

    References:
    http://emedicine.medscape.com/articl...58-overview#a7











    Last edited by Medical Photos; 09-27-2015 at 04:38 PM.

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