What is the most appropriate next step for a 66-year-old woman with progressive dysphagia (difficulty swallowing), regurgitation of food, and recurrent pneumonia, diagnosed with a condition likely causing esophageal obstruction, such as Zenker's diverticulum?

From the Guidelines

The most appropriate next step for this 66-year-old woman with progressive dysphagia, food regurgitation, and recurrent pneumonia likely due to Zenker's diverticulum is to refer her for surgical consultation for potential management. The patient's symptoms, including progressive dysphagia to solids and liquids, regurgitation of food, and recurrent pneumonia, suggest a significant esophageal obstruction that requires definitive treatment. Given the presence of a Zenker's diverticulum, which is an outpouching of the posterior pharyngeal wall that traps food, the patient is at risk for aspiration pneumonia, malnutrition, and dehydration.

• The UK guidelines on oesophageal dilatation in clinical practice 1 suggest that upper oesophageal sphincter disturbances, including those associated with Zenker's diverticulum, can be treated with dilatation to relieve symptoms.
• However, considering the patient's recurrent pneumonia and progressive symptoms, a more definitive treatment approach is necessary.
• Surgical consultation is recommended to discuss potential management options, including open surgical diverticulectomy, which may be necessary depending on the size of the diverticulum and the patient's overall health status.
• Until definitive treatment, the patient should be advised to eat slowly, take small bites, chew thoroughly, and maintain an upright position during and after meals to minimize aspiration risk.
• Soft or pureed foods may be easier to swallow, but these measures are only temporary and do not address the underlying cause of the symptoms.
• Conservative management alone is inadequate for progressive symptoms, especially with recurrent pneumonia indicating aspiration events.

From the Research

Treatment Options for Zenker's Diverticulum

The patient's symptoms, such as progressive dysphagia, regurgitation of food, and recurrent pneumonia, are consistent with Zenker's diverticulum. The barium esophagram results are not provided, but based on the symptoms, the following treatment options can be considered:

• Surgical Consultation: Surgical treatment of Zenker's diverticulum, including diverticulectomy, diverticulopexy, and cricopharyngeal myotomy, has been shown to be effective in managing the condition 2, 3, 4.
• Endoscopic Removal: Endoscopic diverticulotomy has been proposed as a minimally invasive alternative to open surgery, with advantages including less trauma and lower complication rates 2, 5.
• Dilation with a Balloon: There is no evidence to support the use of balloon dilation as a primary treatment for Zenker's diverticulum.
• Conservative Management: Conservative management may not be suitable for this patient, given the severity of her symptoms and the risk of recurrent pneumonia.

Considerations for Treatment

When choosing a treatment option, the following factors should be considered:

• The patient's age and overall health status
• The size and location of the diverticulum
• The presence of any underlying conditions that may affect treatment outcomes
• The potential risks and benefits of each treatment option

Recommended Next Step

Based on the available evidence, surgical consultation for potential management is the most appropriate next step for this patient 2, 3, 4. This will allow for a thorough evaluation of the patient's condition and discussion of the available treatment options, including diverticulectomy, diverticulopexy, and cricopharyngeal myotomy. Endoscopic diverticulotomy may also be considered as a minimally invasive alternative to open surgery 2, 5.