Zenker diverticulum
Zenker diverticulum is a pharyngoesophageal false diverticulum that herniates through Killian triangle above a hypertonic, poorly relaxing cricopharyngeus, producing oropharyngeal dysphagia, regurgitation of undigested food hours after eating, halitosis, and aspiration in older adults. Barium esophagram is the confirmatory study, blind endoscopy or nasogastric intubation must be avoided, and definitive treatment is cricopharyngeal myotomy combined with diverticulectomy, diverticulopexy, or endoscopic stapling.
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What this article covers
- Overview
Definition: Zenker diverticulum is an acquired pharyngoesophageal false (pulsion) diverticulum, a mucosal and submucosal outpouching without a muscular wall, that herniates posteriorly through…
- Epidemiology
Age distribution: predominantly a disease of older adults, most prevalent in the seventh to ninth decades of life; it is rare before middle age.
- Risk factors
Advanced age: age-related decline in cricopharyngeal compliance and coordination is the dominant predisposing factor.
- Pathophysiology
Discoordinated swallow mechanics: the pharyngeal constrictors contract to propel the bolus while the cricopharyngeus fails to relax fully or in time, so pressure inside the pharynx rises sharply…
- Clinical features
Oropharyngeal dysphagia: difficulty initiating swallowing, often progressive, and the presenting symptom in most patients.
- Differential diagnosis
Achalasia: presents with simultaneous solid and liquid dysphagia from the outset rather than the food-retention pattern of Zenker diverticulum, with a dilated esophagus and bird-beak narrowing at the…
- Diagnosis
Clinching basis: the diagnosis is confirmed radiographically, not endoscopically or clinically, by demonstrating a posterior outpouching arising above the cricopharyngeus on contrast esophagram…
- Management
Small, asymptomatic diverticula: observe without intervention; incidentally discovered small pouches causing no dysphagia, regurgitation, or aspiration do not require treatment.
- Complications
Aspiration pneumonia: the most feared complication, from nocturnal spillage of retained food and secretions into the airway; can be recurrent if the diverticulum is not addressed.
- Prognosis
Excellent with definitive repair: cricopharyngeal myotomy combined with diverticulectomy, diverticulopexy, or endoscopic stapling resolves dysphagia and regurgitation in most patients and eliminates…
- Prevention
No primary prevention exists: because the diverticulum arises from age-related cricopharyngeal dysfunction and an inherent anatomic weakness in Killian triangle, there is no screening test or…
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Related articles
- Dysphagia (oral and esophageal)
Dysphagia is difficulty swallowing, and the history alone localizes it to oropharyngeal disease, marked by choking or nasal regurgitation at the start of a swallow, or esophageal disease, marked by food sticking seconds later. Esophageal dysphagia with solids alone points to a mechanical obstruction worked up first with upper endoscopy, while dysphagia for solids and liquids together points to a motility disorder worked up with barium esophagram and manometry.
- Achalasia
Achalasia is a primary esophageal motility disorder from myenteric plexus degeneration that causes failure of lower esophageal sphincter relaxation and aperistalsis, producing dysphagia to solids and liquids with regurgitation. Diagnosis requires endoscopy to exclude pseudoachalasia followed by esophageal manometry, and definitive treatment is pneumatic dilation, laparoscopic Heller myotomy, or POEM.
- Esophageal stricture
Esophageal stricture is a fixed luminal narrowing that produces progressive dysphagia to solids, most often a benign peptic stricture from chronic reflux but always requiring endoscopy with biopsy to exclude malignancy. Management is endoscopic dilation of the narrowed segment plus treatment of the underlying cause, with stenting or resection reserved for malignant obstruction.