Zenker's Diverticulum

What is Zenker’s Diverticulum?

Zenker’s diverticulum is a condition in which a pouch (diverticulum) forms in the wall of the pharynx (throat) just above the upper oesophagal sphincter. It is a rare condition that occurs when the muscle at the bottom of the oesophagus (the sphincter) doesn’t work properly, allowing food and other materials to flow back up into the pharynx and form a pouch. Symptoms of Zenker’s diverticulum may include difficulty swallowing, regurgitation of food, and a chronic cough. The main treatment for Zenker’s diverticulum is surgery to remove the diverticulum and repair the sphincter.

Table of Contents

Symptoms of Zenker’s Diverticulum

Zenker’s diverticulum is a condition related to the oesophagus (the tube that carries food from the mouth to the stomach), therefore, most of the symptoms and signs are also associated with the oesophagus and its surroundings. The following are the symptoms of Zenker’s diverticulum:

Difficulty swallowing (dysphagia): The pouch can obstruct the passage of food, making it difficult to swallow.
Regurgitation: The food that is not able to pass through the pouch can leak back into the mouth, causing regurgitation.
Chest pain or discomfort: This can occur due to the pressure of food in the pouch on the wall of the oesophagus.
Chronic Coughing: Coughing can occur due to food particles that have leaked back into the mouth.
Choking: This can occur if food gets stuck in the pouch and is not able to pass through.
Bad breath: This can occur due to the accumulation of food particles in the pouch.
Voice changes: This can occur due to pressure on the larynx (voice box) from the pouch.

It is important to seek medical attention if you experience any of these symptoms as they can be indicative of Zenker’s diverticulum.

Causes of Zenker’s Diverticulum

Zenker’s diverticulum (ZD) results from posterior herniation (abnormal protrusion of tissue) of oesophagal mucosa into Killian’s triangle, an area of least resistance situated above the cricopharyngeus (CP) muscle and below the inferior pharyngeal constrictor muscle. Over time, the pouch can enlarge as the muscles below it tighten excessively. Food can catch in this pouch or it can cause an obstruction. It can also make it difficult to take medications – particularly pills, which could get caught. ZD is actually a pseudodiverticulum since the Zenker’s pouch contains only oesophagal mucosa and submucosa. ZD can cause dysphagia and the pooling of food within the diverticulum, which can cause frequent regurgitation and can lead to aspiration pneumonia.

Risk Factors of Zenker’s Diverticulum

Zenker’s Diverticulum is caused by a weakness in the muscles of the oesophagus. The following factors can contribute to the development of Zenker’s Diverticulum:

Age: The condition is more common in older adults.
Abnormal pressure in the oesophagus: Conditions such as coughing, straining during bowel movements, and frequent swallowing can increase the pressure in the oesophagus, leading to a weak spot.
Muscle weakness: Certain medical conditions such as achalasia, which affects the muscles in the oesophagus, can cause Zenker’s Diverticulum.
Heredity: A genetic predisposition may play a role in the development of Zenker’s Diverticulum.
Chronic inflammation: Inflammation of the oesophagus caused by conditions such as gastroesophageal reflux disease (GERD) can weaken the muscles and lead to the formation of a diverticulum.
Surgery: Prior surgeries of the neck, oesophagus, or chest can cause damage to the muscles in the oesophagus, leading to the formation of a Zenker’s Diverticulum.

Complications of Zenker’s Diverticulum

Although this condition is relatively common and often asymptomatic, it can lead to several complications if left untreated. Some of the common complications of Zenker’s diverticulum include:

Aspiration: Food and liquids can get stuck in the pouch and lead to aspiration, which is the inhalation of food particles into the lungs. This can cause pneumonia and other respiratory infections.
Oesophageal obstruction: The pouch can become enlarged and block the oesophagus, making it difficult to swallow food and liquids.
Regurgitation: The contents of the pouch can reflux back into the mouth, leading to the regurgitation of undigested food.
Choking: If the pouch becomes enlarged, it can cause choking or gagging during meals, because the pouch can collect food particles, which can become trapped and cause choking. Other symptoms include difficulty swallowing, regurgitation, and coughing.
Bleeding: Bleeding can be caused by various factors, including the accumulation of food particles in the pouch, leading to inflammation and erosion of the surrounding blood vessels. The bleeding can range from minor to severe and in some cases can lead to life-threatening anaemia.
Fistula Formation: If the diverticulum becomes infected, it can lead to the formation of a fistula, which is an abnormal connection between the diverticulum and another structure, such as the trachea, bronchus, or neck.The symptoms of fistula formation due to Zenker’s diverticulum include difficulty swallowing, hoarseness, coughing, and recurrent aspiration. In some cases, patients may also experience chest pain, shortness of breath, or recurrent infections.
Laryngeal Nerve Paralysis: Laryngeal nerve paralysis, also known as vocal cord paralysis, is a condition in which the nerves that control the larynx (voice box) are damaged or do not function properly. This can result in difficulties with speaking, swallowing, and breathing.

Treatment for Zenker’s diverticulum typically involves a surgical intervention to remove the pouch and repair the oesophagus. Early diagnosis and treatment can help prevent complications and improve the quality of life for patients with this condition.

Diagnosis of Zenker’s Diverticulum

The above-mentioned signs and symptoms can be helpful in determining the existence of diverticulum. However, there are some specific diagnostic tests used by clinicians to diagnose the condition;

Endoscopy: An endoscopy may be performed to diagnose the condition. An endoscopy is a procedure in which a thin, flexible tube equipped with a camera is inserted into the mouth and passed down the throat to the oesophagus. The doctor will be able to visualize the pouch and determine its size and location.
Barium Swallow Test: A barium swallow test is a diagnostic procedure used to identify and evaluate Zenker’s diverticulum. This test involves consuming a liquid mixture of barium sulfate, which is a contrast agent and then taking X-rays of the digestive system. The barium helps to highlight the anatomy of the oesophagus, allowing the doctor to see any abnormalities or abnormalities such as a Zenker’s diverticulum.The barium swallow test is a non-invasive and safe procedure that is commonly used to diagnose Zenker’s diverticulum. The results of the test can help the doctor determine the best course of treatment for the patient.
CT scan or MRI: A CT scan or MRI can be used to diagnose Zenker’s diverticulum. The CT scan provides detailed images of the neck and chest area, allowing for a clear visual of the diverticulum and its location. The MRI provides similar images but also allows for a more in-depth look at the surrounding tissues and structures. Both imaging tests are non-invasive and help provide an accurate diagnosis for Zenker’s diverticulum.
Manometry: Manometry is a diagnostic test used to assess the pressure and movement of the upper oesophagus and swallowing muscles. Manometry can be used to diagnose Zenker’s diverticulum as it can help determine if the diverticulum is causing problems with swallowing or speaking. The test involves inserting a thin tube through the nose and into the oesophagus. The tube measures the pressure and movement of the muscles in the throat and oesophagus.A diagnosis of Zenker’s diverticulum can be confirmed if the manometry test shows increased pressure and altered muscle movement in the area of the diverticulum. This information helps the doctor determine the best course of treatment, which may involve surgery to remove the pouch.
Oesophageal pH Monitoring:Oesophageal pH monitoring is a diagnostic test used to measure the acidity level of the oesophagus and stomach. The test involves inserting a thin probe through the nose or mouth into the oesophagus. The probe is connected to a recording device that measures the pH level of the esophagus and stomach over a period of 24 hours. This test can help diagnose Zenker’s diverticulum by showing if there is any reflux of stomach acid into the pouch of the diverticulum, leading to irritation and inflammation of the surrounding tissue.

Confirming a diagnosis of Zenker’s diverticulum is important in order to determine the best course of treatment.

Preventive Measures

Some cases of Zenker’s Diverticulum are congenital, and there is no possibility of prevention. In case the diverticulum is because of abnormal pressure on the oesophagus, the risk can be reduced by an early diagnosis and prompt treatment. Coughing gently, not straining during bowel movements, good oral hygiene, avoiding eating too quickly, and avoiding foods that are difficult to swallow can help prevent the formation of the condition.

In some cases, modifying the diet to include soft, easily digestible foods and avoiding foods that cause gas can help prevent the development of Zenker’s diverticulum. It is also important to seek medical attention if you experience any symptoms of the condition, such as difficulty swallowing, coughing, or pain in the neck or throat.

Treatment of Zenker’s Diverticulum

The best treatment option for Zenker’s diverticulum will depend on the severity of symptoms and the individual patient’s health. A gastroenterologist or a thoracic surgeon can help determine the best course of treatment. The treatment options for Zenker’s diverticulum include:

Endoscopic diverticulectomy

Endoscopic diverticulectomy is a minimally invasive procedure used to treat Zenker’s Diverticulum. During the procedure, a flexible endoscope is inserted into the mouth and advanced down the throat to the site of the diverticulum. The doctor will then use the endoscope to identify the pouch and create a small opening in the wall of the pouch. This allows food and other materials to pass through the opening and into the oesophagus, reducing the symptoms of Zenker’s Diverticulum.

Endoscopic diverticulectomy is a safe and effective procedure with a high success rate. It is performed under local anaesthesia and sedation and typically takes 30 minutes to an hour to complete. Recovery time is usually short, with most patients returning to normal activities within a few days.

Endoscopic diverticulectomy has several advantages over traditional surgical methods, including a lower risk of complications, less pain, and a quicker recovery time. It is also a less invasive option that allows patients to avoid the need for general anaesthesia and a prolonged hospital stay.

Overall, endoscopic diverticulotomy is an excellent option for treating Zenker’s Diverticulum, providing a minimally invasive solution to a complex problem. If you are experiencing symptoms of Zenker’s Diverticulum, it is important to talk to your doctor about all of your treatment options, including endoscopic diverticulectomy.

Open diverticulectomy

Zenker’s Diverticulum is a medical condition where a pouch forms in the wall of the oesophagus, causing difficulty in swallowing, regurgitation of food, and bad breath. It is typically treated with a surgical procedure known as an open diverticulectomy.

The open diverticulectomy procedure involves making an incision in the neck, exposing the oesophagus and the Zenker’s pouch. The pouch is then dissected from the surrounding tissues and removed. The opening in the oesophagus wall is then closed with sutures or a staple gun, and the incision is closed.

The procedure takes approximately 1-2 hours to complete and is performed under general anaesthesia. The patient may stay in the hospital for 1-2 days for observation and recovery, and it typically takes 2-3 weeks for the patient to return to normal activities.

Risks associated with open diverticulectomy include bleeding, infection, injury to the oesophagus or surrounding tissues, and difficulty swallowing or speaking. These risks can usually be managed with proper care and follow-up.

Overall, open diverticulectomy is a safe and effective surgical procedure that can alleviate the symptoms associated with Zenker’s Diverticulum, allowing the patient to resume normal activities and improve their quality of life.

Laparoscopic diverticulectomy

Laparoscopic diverticulectomy is a surgical procedure that involves removing the pouch through small incisions in the abdomen. The procedure is performed under general anesthesia and typically lasts between two and four hours.

During the procedure, the surgeon uses a laparoscope (a small camera) to view the inside of the abdomen and to guide the surgical instruments. The pouch is dissected away from the esophagus and removed through one of the small incisions. The opening in the esophagus is then closed and the incisions are closed with sutures or staples.

Laparoscopic diverticulectomy is considered a less invasive option compared to traditional open surgery, as it typically requires fewer incisions and results in less pain, scarring, and a shorter recovery time.

After the surgery, patients may experience soreness and discomfort in the incision area, but this usually resolves within a few days. A soft diet may be recommended for a few weeks to allow the oesophagus to heal.

Peroral endoscopic myotomy (POEM)

Peroral endoscopic myotomy (POEM) is a minimally invasive surgical procedure used to treat Zenker’s diverticulum. During the procedure, a small endoscope is passed through the mouth and into the oesophagus, and the muscle fibres around the diverticulum are cut, which helps to relieve the pressure and allow food and saliva to pass freely.

POEM offers several benefits over traditional surgical methods, including:

Minimal invasiveness: The procedure is performed through the mouth, avoiding any incisions or scarring on the neck or chest.
Short recovery time: POEM typically requires only an overnight stay in the hospital, with patients returning to normal activities within a few days.
Improved results: POEM has been shown to provide effective relief of symptoms and improvement in quality of life for patients with Zenker’s diverticulum.
Low complication rate: POEM has a low rate of complications, including infection, bleeding, and perforation of the esophagus.

Overall, POEM is a safe and effective alternative to traditional surgical methods for treating Zenker’s diverticulum, providing patients with improved quality of life and a quick recovery.

Medical management of Zenker’s Diverticulum

In some cases, Zenker’s diverticulum can be managed with medications and lifestyle changes, such as avoiding foods that can cause symptoms and swallowing exercises.

Dietary modification: Patients may be advised to modify their diet to reduce the size of the diverticulum, such as avoiding large meals, eating smaller, more frequent meals, and avoiding crunchy or hard-to-chew foods.
Medications: In some cases, medications such as proton pump inhibitors, histamine-2 receptor blockers, and pro-motility drugs may be prescribed to relieve symptoms of Zenker’s diverticulum.