What is the characteristic of traction diverticula in esophageal diverticula?

Characteristics of Esophageal Diverticula

Traction diverticula are true diverticula, not false diverticula, containing all layers of the esophageal wall. This is in contrast to pulsion diverticula, which are false diverticula containing only mucosa and submucosa.

Types of Esophageal Diverticula

Traction Diverticula

• Definition: True diverticula that contain all layers of the esophageal wall (mucosa, submucosa, and muscle layer) 1
• Location: Typically found in the middle third of the thoracic esophagus in a peribronchial location 1
• Etiology: Result from inflammatory processes in the mediastinum (such as tuberculosis or histoplasmosis) causing desmoplastic reactions in paraesophageal tissue 1, 2
• Morphology: Conical, broad-mouthed diverticula that often project to the right side due to close association with subcarinal lymph nodes 1

Pulsion Diverticula

• Definition: False diverticula that lack a muscular coat, with walls formed only by mucosa and submucosa 1
• Location: Most commonly found in the distal esophagus (epiphrenic) or at the level of the cricopharyngeus muscle (Zenker's), not primarily in the midesophagus 3
• Etiology: Occur due to increased intraluminal pressure, often associated with underlying esophageal motility disorders 3, 4
• Types: Zenker's diverticulum, mid-esophageal diverticulum, and epiphrenic diverticulum 3

Clinical Presentation and Diagnosis

Symptoms

• Traction diverticula: Dysphagia, postural regurgitation, retrosternal pain, heartburn 1
• Pulsion diverticula: Chest-related symptoms or esophageal symptoms related to underlying motility disorders 3
• Both types can present with pulmonary symptoms ranging from mild nocturnal cough to aspiration 1

Diagnostic Evaluation

• Barium esophagram (recommended by American College of Radiology as initial diagnostic test) 5
• Chest X-ray
• Esophageal manometry (particularly important for pulsion diverticula to identify associated motility disorders) 1, 3
• CT scan and endoscopy for further evaluation 3

Treatment Approaches

Traction Diverticula

• Treatment of the underlying inflammatory cause 1
• Surgical resection may be necessary in symptomatic patients 1

Pulsion Diverticula

• Surgical options: Diverticulectomy or diverticulopexy with myotomy for symptomatic and large diverticula 3
• Endoscopic techniques: Increasingly used, particularly for Zenker's diverticulum 3
• Per-oral endoscopic myotomy (POEM): Emerging technique for treatment of diverticula associated with motility disorders 4
• Myotomy: Not always indicated for pulsion diverticula; decision depends on:
  • Presence and type of associated motility disorder
  • Size of the diverticulum
  • Severity of symptoms 3, 4

Complications

• Bronchoesophageal fistula (rare) 6
• Aspiration pneumonia 4
• Upper gastrointestinal bleeding (rare) 1

Key Points for Clinical Practice

• Traction diverticula are true diverticula containing all layers of the esophageal wall
• Pulsion diverticula are most commonly found in the distal esophagus or at the cricopharyngeus muscle, not primarily in the midesophagus
• Pulsion diverticula are associated with motility disorders, not primarily with enlarged lymph nodes
• Myotomy is not always indicated for pulsion diverticula; treatment should be based on the presence of symptoms, size of the diverticulum, and associated motility disorders

Understanding these distinctions is crucial for proper diagnosis and management of esophageal diverticula to reduce morbidity and improve quality of life.