What are the characteristics and treatment options for esophageal diverticula?

Characteristics and Treatment of Esophageal Diverticula

Pulsion diverticula are true diverticula that are more common in the distal esophagus (epiphrenic) rather than midesophagus, and myotomy is not always indicated but should be performed for symptomatic cases with underlying motility disorders. 1, 2

Types and Characteristics of Esophageal Diverticula

Pulsion vs. Traction Diverticula

• Pulsion diverticula occur due to increased intraluminal pressure and are true diverticula (not false as suggested in option a) 2
• Traction diverticula are caused by pulling forces from outside the esophagus, often from inflamed lymph nodes
• Pulsion diverticula can be classified by location:
  • Zenker's diverticulum (pharyngoesophageal)
  • Mid-esophageal diverticulum (least common)
  • Epiphrenic diverticulum (distal esophagus)

Location and Association

• Pulsion diverticula are more common in the distal esophagus (epiphrenic) rather than midesophagus (contrary to option b) 2, 3
• Pulsion diverticula are associated with underlying esophageal motility disorders rather than enlarged lymph nodes (contrary to option c) 2, 4
• Traction diverticula (not pulsion) are typically associated with inflammatory processes and enlarged lymph nodes 5

Diagnostic Approach

Recommended Imaging

• Barium studies are highly effective for detecting structural abnormalities and are preferred for initial evaluation 1
• CT/MRI scans may be indicated for comprehensive evaluation, especially for symptomatic patients 1
• Esophageal manometry is essential to identify underlying motility disorders that are frequently associated with diverticula 2, 5
• Endoscopy should be performed to rule out malignancy, although this is a rare complication 2, 3

Treatment Approach

Indications for Intervention

• Asymptomatic diverticula generally do not require treatment 4, 1
• Intervention is indicated when:
  • Symptoms become significant (dysphagia, regurgitation, chest pain)
  • Evidence of aspiration occurs
  • Significant enlargement is noted
  • Quality of life is impacted 1

Treatment Options

• Conservative management is appropriate for small, asymptomatic diverticula:

  • Dietary modifications (eating slowly, chewing thoroughly)
  • Semi-solid diet if needed
  • Swallowing therapy with a speech-language pathologist 1

• Surgical management depends on diverticulum size and symptoms:

  • Small diverticula may be left in place without resection
  • Medium-sized diverticula may be treated by diverticulectomy, diverticulopexy, or esophagodiverticulostomy (for Zenker's)
  • Larger diverticula typically require resection 4

Role of Myotomy

• Myotomy is NOT always indicated for pulsion diverticula (contrary to option d) but should be included when:
  • There is an underlying motility disorder
  • The patient is symptomatic 4, 3
• When performed, myotomy should extend:
  • Distally 1.5-2 cm into the stomach
  • Proximally at least to the neck of the diverticulum 3
• An anti-reflux procedure is often recommended with myotomy to prevent post-operative GERD 3

Surgical Approaches

• Minimally invasive techniques (endoscopic, laparoscopic) are increasingly used with promising results 2, 5
• Open surgical techniques remain standard for complex cases 5
• Endoscopic techniques are now common for Zenker's diverticulum 2

Pitfalls and Caveats

• Pulmonary symptoms may be the sole manifestation of esophageal diverticula in some patients, leading to delayed diagnosis 3, 6
• Risk of aspiration is significant (reported in up to 45% of patients) and can lead to life-threatening complications 6
• Surgical techniques for esophageal diverticula are demanding and associated with significant morbidity; procedures should be performed by experienced esophageal surgeons 4, 5
• Follow-up is essential for patients managed conservatively, with repeat barium swallow recommended at 6-12 months to assess for progression 1