Jump to content

Zenker's diverticulum: Difference between revisions

From Wikipedia, the free encyclopedia
Browse history interactively
← Previous edit
Content deleted Content added
VisualWikitext
No edit summary
 
(47 intermediate revisions by 24 users not shown)
Line 1: Line 1:
{{distinguish|Pharyngeal pouch (embryology)}}
{{Infobox disease |
{{Infobox medical condition (new)
Name = Zenker's diverticulum |
Image = ZenkerSchraeg.gif |
| name = Zenker's diverticulum
Caption = |
| image = ZenkerSchraeg.gif
DiseasesDB = 31174 |
| caption =
ICD10 = {{ICD10|K|22|5|k|20}} |
| pronounce =
ICD9 = {{ICD9|530.6}} |
| field = [[Gastroenterology]]
| synonyms = Pharyngoesophageal diverticulum, pharyngeal pouch, hypopharyngeal diverticulum
⚫
ICDO = |
OMIM = |
| symptoms =
MedlinePlus = |
| complications =
| onset =
⚫
eMedicineSubj = med |
| duration =
⚫
eMedicineTopic = 2777 |
MeshID = D016672 |
| types =
| causes =
| risks =
| diagnosis =
| differential =
| prevention =
| treatment =
| medication =
| prognosis =
| frequency =
| deaths =
}}
}}
A '''Zenker's diverticulum''', also '''pharyngoesophageal diverticulum''', also '''pharyngeal pouch''', also '''hypopharyngeal diverticulum''', is a [[diverticulum]] of the [[mucosa]] of the [[human pharynx|pharynx]], just above the [[cricopharyngeal muscle]] (i.e. above the upper [[sphincter]] of the [[esophagus]]). It is a false diverticulum (not involving all layers of the esophageal wall).
A '''Zenker's diverticulum''', also '''pharyngeal pouch''', is a [[diverticulum]] of the [[mucosa]] of the [[human pharynx]], just above the [[cricopharyngeal muscle]] (i.e. above the upper [[sphincter]] of the [[esophagus]]). It is a pseudo diverticulum or false diverticulum (only involving the mucosa and submucosa of the esophageal wall, not the adventitia), also known as a pulsion diverticulum.


It was named in 1877 by [[Germany|German]] [[pathologist]] [[Friedrich Albert von Zenker]].<ref>{{WhoNamedIt|synd|2461}}</ref><ref>F. A. Zenker and Hugo Wilhelm von Ziemssen. Krankheiten des Oesophagus. Leipzig, 1867.</ref>
It was named in 1877 after [[Germany|German]] [[pathologist]] [[Friedrich Albert von Zenker]].<ref>{{WhoNamedIt|synd|2461}}</ref><ref>{{cite book |first1= FA |last1= Zenker |first2= HW |last2= von Ziemssen |title= Krankheiten des Oesophagus |location= Leipzig |date= 1867 |publisher= F.C.W. Vogel}}</ref>


== Signs and symptoms ==
== Signs and symptoms ==


In simple words, when there is excessive pressure within the lower [[human pharynx|pharynx]], the weakest portion of the pharyngeal wall balloons out, forming a [[diverticulum]] which may reach several centimetres in diameter.
When there is excessive pressure within the lower [[human pharynx|pharynx]], the weakest portion of the pharyngeal wall balloons out, forming a [[diverticulum]] which may reach several centimetres in diameter.


More precisely, while traction and pulsion mechanisms have long been deemed the main factors promoting development of a Zenker's diverticulum, current consensus considers occlusive mechanisms to be most important: uncoordinated swallowing, impaired relaxation and spasm of the [[cricopharyngeus]] muscle lead to an increase in pressure within the distal pharynx, so that its wall herniates through the point of least resistance (known as [[Killian's triangle]], located superior to the cricopharyngeus muscle and inferior to the inferior constrictor muscles). The result is an outpouching of the posterior pharyngeal wall, just above the esophagus.<ref name="pmid12903677">{{cite journal |author=van Overbeek JJ |title=Pathogenesis and methods of treatment of Zenkr's diverticulum |journal=Ann. Otol. Rhinol. Laryngol. |volume=112 |issue=7 |pages=583–93 |date=July 2003 |pmid=12903677 |doi= |url=}}</ref>
While traction and pulsion mechanisms have long been deemed the main factors promoting development of a Zenker's diverticulum, current consensus considers occlusive mechanisms to be most important: uncoordinated swallowing, impaired relaxation and spasm of the [[cricopharyngeus]] muscle lead to an increase in pressure within the distal pharynx, so that its wall herniates through the point of least resistance (known as [[Killian's triangle]], located superior to the cricopharyngeus muscle and inferior to the thyropharyngeus muscle. Thyropharyngeus and cricopharyngeus are the superior and inferior parts of inferior constrictor muscle of pharynx respectively). The result is an outpouching of the posterior pharyngeal wall, just above the esophagus.<ref name="pmid12903677">{{cite journal |last=van Overbeek |first= JJ |title=Pathogenesis and methods of treatment of Zenkr's diverticulum |journal=Ann. Otol. Rhinol. Laryngol. |volume=112 |issue=7 |pages=583–93 |date=July 2003 |pmid=12903677 |doi= 10.1177/000348940311200703|s2cid= 31405929 }}</ref>


While it may be asymptomatic, Zenker diverticulum can present with the following symptoms:
While it may be asymptomatic, Zenker diverticulum can present with the following symptoms:
* [[Dysphagia]] (difficulty swallowing), and sense of a lump in the neck
* [[Dysphagia]] (difficulty swallowing), and sense of a lump in the throat
* Food might get trapped in the outpouching, leading to:
* Food might get trapped in the outpouching, leading to:
** [[Regurgitation (digestion)|Regurgitation]], reappearance of ingested food in the mouth
** [[Regurgitation (digestion)|Regurgitation]], reappearance of ingested food in the mouth
** [[Cough]], due to food regurgitated into the airways)
** [[Cough]], due to food regurgitated into the airway
** [[Halitosis]], smelly breath, as stagnant food is digested by microorganisms
** [[Halitosis]], smelly breath, as stagnant food is digested by microorganisms
** Infection
** Infection
It rarely, if ever, causes any pain.
It rarely, if ever, causes any pain.


[[Cervical web]]s are seen associated in 50% of patients with this condition.
[[Esophageal web]]s are seen associated in 50% of patients with this condition.


Rarer forms of cervical esophageal diverticula are the [[Killian-Jamieson diverticulum|Killian's diverticulum]] and the [[Laimer's diverticulum]]. Killian's diverticulum is formed in the Killian-Jamiseon triangle (located inferior to the cricopharyngeus on both sides of this muscle's insertion into the cricoid cartilage). Laimer's diverticulum is formed in Laimer's triangle (located inferior to the cricopharyngeus in the posterior midline above the confluence of the longitudinal layer of esophageal muscle). Laimer's triangle is covered only by the circular layer of esophageal muscle.
Rarer forms of cervical esophageal diverticula are the [[Killian-Jamieson diverticulum|Killian's diverticulum]] and the [[Laimer's diverticulum]]. [[Killian–Jamieson diverticulum|Killian's diverticulum]] is formed in the Killian-Jamiseon triangle (between the oblique and transverse fibers of the [[cricopharyngeus muscle]]). [[Laimer's diverticulum]] is formed in Laimer's triangle (located inferior to the cricopharyngeus in the posterior midline above the confluence of the longitudinal layer of the superior esophageal circular muscle). Laimer's triangle is covered only by the circular layer of esophageal muscle.


== Diagnosis ==
== Diagnosis ==
[[File:Zenker22015Lateral.JPG|thumb|Lateral X-ray of a Zenker's diverticulum]]

[[File:Zenker1.JPG|thumb|AP X-ray of a Zenker's diverticulum]]
The simple [[barium swallow]] will normally reveal the [[diverticulum]]. An upper GI endoscopy also shows the diverticulum. Sipping contrast and taking a CT also gives a definite diagnosis.
A combination of the simple [[barium swallow]] and a thorough endoscopy will normally confirm the [[diverticulum]].<ref name="pmid26843913">{{cite journal | vauthors = Bencini L, Moraldi L, Bartolini I, Coratti A | title = Esophageal surgery in minimally invasive era | journal = World J Gastrointest Surg | volume = 8 | issue = 1 | pages = 52–64 | date = January 2016 | pmid = 26843913 | pmc = 4724588 | doi = 10.4240/wjgs.v8.i1.52 | doi-access = free }}</ref>


== Treatment ==
== Treatment ==


If small and asymptomatic, no treatment is necessary. Larger, symptomatic cases of Zenker's diverticulum have been traditionally treated by neck [[surgery]] to resect the [[diverticulum]] and incise the [[cricopharyngeus]] muscle. However, in recent times non-surgical endoscopic techniques have gained more importance (as they allow for much faster recovery), and the currently preferred treatment is endoscopic stapling<ref name="pmid15453934">{{cite journal |author=Sen P, Bhattacharyya AK |title=Endoscopic stapling of pharyngeal pouch |journal=J Laryngol Otol |volume=118 |issue=8 |pages=601–6 |date=August 2004 |pmid=15453934 |doi=10.1258/0022215041917817 |url=}}</ref><ref name="pmid12782805">{{cite journal |author=Chang CY, Payyapilli RJ, Scher RL |title=Endoscopic staple diverticulostomy for Zenker's diverticulum: review of literature and experience in 159 consecutive cases |journal=Laryngoscope |volume=113 |issue=6 |pages=957–65 |date=June 2003 |pmid=12782805 |doi= 10.1097/00005537-200306000-00009|url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0023-852X&volume=113&issue=6&spage=957}}</ref> (i.e. diverticulotomy with staples ). This may be performed through a diverticuloscope. Other methods include fibreoptic diverticular repair.<ref name="pmid15966520">{{cite journal |author=Altman JI, Genden EM, Moche J |title=Fiberoptic endoscopic-assisted diverticulotomy: a novel technique for the management of Zenker's diverticulum |journal=Ann. Otol. Rhinol. Laryngol. |volume=114 |issue=5 |pages=347–51 |date=May 2005 |pmid=15966520 |doi= |url=}}</ref>
If small (ie, <2 cm) and asymptomatic, no treatment is necessary.<ref>{{Citation |last=Nesheiwat |first=Zeid |title=Zenker Diverticulum |date=2023 |url=http://www.ncbi.nlm.nih.gov/books/NBK499996/ |work=StatPearls |access-date=2023-11-07 |place=Treasure Island (FL) |publisher=StatPearls Publishing |pmid=29763172 |last2=Antunes |first2=Catiele}}</ref> Larger, symptomatic cases of Zenker's diverticulum have been traditionally treated by neck [[surgery]] to resect the [[diverticulum]] and incise the [[cricopharyngeus]] muscle. However, in recent times non-surgical endoscopic techniques have gained more importance (as they allow for much faster recovery), and the currently preferred treatment is endoscopic stapling<ref name="pmid15453934">{{cite journal |last1=Sen |first1= P |last2= Bhattacharyya |first2= AK |title=Endoscopic stapling of pharyngeal pouch |journal=J Laryngol Otol |volume=118 |issue=8 |pages=601–6 |date=August 2004 |pmid=15453934 |doi=10.1258/0022215041917817 |s2cid= 32002606 }}</ref><ref name="pmid12782805">{{cite journal |last1= Chang |first1= CY |last2= Payyapilli |first2= RJ |last3= Scher |first3= RL |title=Endoscopic staple diverticulostomy for Zenker's diverticulum: review of literature and experience in 159 consecutive cases |journal=Laryngoscope |volume=113 |issue=6 |pages=957–65 |date=June 2003 |pmid=12782805 |doi= 10.1097/00005537-200306000-00009|s2cid= 6206165 }}</ref> (i.e. diverticulotomy with staples ). This may be performed through a diverticuloscope. Other methods include fibreoptic diverticular repair.<ref name="pmid15966520">{{cite journal |last1= Altman |first1= JI |last2= Genden |first2= EM |last3= Moche |first3= J |title=Fiberoptic endoscopic-assisted diverticulotomy: A novel technique for the management of Zenker's diverticulum |journal=Ann. Otol. Rhinol. Laryngol. |volume=114 |issue=5 |pages=347–51 |date=May 2005 |pmid=15966520 |doi= 10.1177/000348940511400503|s2cid= 39747386 }}</ref>


Other non-surgical treatment modalities also exist, such as endoscopic laser, which recent evidence suggests is less effective than stapling.<ref name="pmid16954989">{{cite journal |author=Miller FR, Bartley J, Otto RA |title=The endoscopic management of Zenker diverticulum: CO2 laser versus endoscopic stapling |journal=Laryngoscope |volume=116 |issue=9 |pages=1608–11 |date=September 2006 |pmid=16954989 |doi=10.1097/01.mlg.0000233508.06499.41 |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?doi=10.1097/01.mlg.0000233508.06499.41}}</ref>
Other non-surgical treatment modalities also exist, such as endoscopic laser, which recent evidence suggests is less effective than stapling.<ref name="pmid16954989">{{cite journal |last1= Miller |first1= FR |last2= Bartley |first2= J |last3= Otto |first3= RA |title=The endoscopic management of Zenker diverticulum: CO2 laser versus endoscopic stapling |journal=Laryngoscope |volume=116 |issue=9 |pages=1608–11 |date=September 2006 |pmid=16954989 |doi=10.1097/01.mlg.0000233508.06499.41 |s2cid= 45791555 }}</ref>


== Epidemiology ==
== Epidemiology ==


Zenker's diverticulum mainly affects older adults. It has an incidence of 2 per 100,000 per year in the UK, but there is significant geographical variation around the world.<ref>{{cite journal|last1=Siddiq|first1=MA|last2=Sood|first2=S|last3=Strachan|first3=D|title=Pharyngeal pouch (Zenker's diverticulum).|journal=Postgraduate medical journal|date=August 2001|volume=77|issue=910|pages=506-11|pmid=11470929}}</ref>
Zenker's diverticulum mainly affects older adults. It has an incidence of 2 per 100,000 per year in the UK, but there is significant geographical variation around the world.<ref>{{cite journal|last1=Siddiq|first1=MA|last2=Sood|first2=S|last3=Strachan|first3=D|title=Pharyngeal pouch (Zenker's diverticulum).|journal=Postgraduate Medical Journal|date=August 2001|volume=77|issue=910|pages=506–11|pmid=11470929|doi=10.1136/pmj.77.910.506|pmc=1742115}}</ref>


== References ==
== References ==
{{reflist|2}}
{{Reflist}}


== External links ==
== External links ==
{{Medical resources
| DiseasesDB = 31174
| ICD10 = {{ICD10|K|22|5|k|20}}
| ICD9 = {{ICD9|530.6}}
⚫
| ICDO =
| OMIM =
| MedlinePlus =
⚫
| eMedicineSubj = med
⚫
| eMedicineTopic = 2777
| MeshID = D016672
}}
* {{EMedicine|med|2777|Zenker's diverticulum}}
* {{EMedicine|med|2777|Zenker's diverticulum}}


Latest revision as of 21:02, 7 November 2023

Not to be confused with Pharyngeal pouch (embryology).
Zenker's diverticulum
Other namesPharyngoesophageal diverticulum, pharyngeal pouch, hypopharyngeal diverticulum
SpecialtyGastroenterology

A Zenker's diverticulum, also pharyngeal pouch, is a diverticulum of the mucosa of the human pharynx, just above the cricopharyngeal muscle (i.e. above the upper sphincter of the esophagus). It is a pseudo diverticulum or false diverticulum (only involving the mucosa and submucosa of the esophageal wall, not the adventitia), also known as a pulsion diverticulum.

It was named in 1877 after German pathologist Friedrich Albert von Zenker.[1][2]

Signs and symptoms

[edit]

When there is excessive pressure within the lower pharynx, the weakest portion of the pharyngeal wall balloons out, forming a diverticulum which may reach several centimetres in diameter.

While traction and pulsion mechanisms have long been deemed the main factors promoting development of a Zenker's diverticulum, current consensus considers occlusive mechanisms to be most important: uncoordinated swallowing, impaired relaxation and spasm of the cricopharyngeus muscle lead to an increase in pressure within the distal pharynx, so that its wall herniates through the point of least resistance (known as Killian's triangle, located superior to the cricopharyngeus muscle and inferior to the thyropharyngeus muscle. Thyropharyngeus and cricopharyngeus are the superior and inferior parts of inferior constrictor muscle of pharynx respectively). The result is an outpouching of the posterior pharyngeal wall, just above the esophagus.[3]

While it may be asymptomatic, Zenker diverticulum can present with the following symptoms:

  • Dysphagia (difficulty swallowing), and sense of a lump in the throat
  • Food might get trapped in the outpouching, leading to:
    • Regurgitation, reappearance of ingested food in the mouth
    • Cough, due to food regurgitated into the airway
    • Halitosis, smelly breath, as stagnant food is digested by microorganisms
    • Infection

It rarely, if ever, causes any pain.

Esophageal webs are seen associated in 50% of patients with this condition.

Rarer forms of cervical esophageal diverticula are the Killian's diverticulum and the Laimer's diverticulum. Killian's diverticulum is formed in the Killian-Jamiseon triangle (between the oblique and transverse fibers of the cricopharyngeus muscle). Laimer's diverticulum is formed in Laimer's triangle (located inferior to the cricopharyngeus in the posterior midline above the confluence of the longitudinal layer of the superior esophageal circular muscle). Laimer's triangle is covered only by the circular layer of esophageal muscle.

Diagnosis

[edit]
Lateral X-ray of a Zenker's diverticulum
AP X-ray of a Zenker's diverticulum

A combination of the simple barium swallow and a thorough endoscopy will normally confirm the diverticulum.[4]

Treatment

[edit]

If small (ie, <2 cm) and asymptomatic, no treatment is necessary.[5] Larger, symptomatic cases of Zenker's diverticulum have been traditionally treated by neck surgery to resect the diverticulum and incise the cricopharyngeus muscle. However, in recent times non-surgical endoscopic techniques have gained more importance (as they allow for much faster recovery), and the currently preferred treatment is endoscopic stapling[6][7] (i.e. diverticulotomy with staples ). This may be performed through a diverticuloscope. Other methods include fibreoptic diverticular repair.[8]

Other non-surgical treatment modalities also exist, such as endoscopic laser, which recent evidence suggests is less effective than stapling.[9]

Epidemiology

[edit]

Zenker's diverticulum mainly affects older adults. It has an incidence of 2 per 100,000 per year in the UK, but there is significant geographical variation around the world.[10]

References

[edit]
  1. ^ synd/2461 at Who Named It?
  2. ^ Zenker, FA; von Ziemssen, HW (1867). Krankheiten des Oesophagus. Leipzig: F.C.W. Vogel.
  3. ^ van Overbeek, JJ (July 2003). "Pathogenesis and methods of treatment of Zenkr's diverticulum". Ann. Otol. Rhinol. Laryngol. 112 (7): 583–93. doi:10.1177/000348940311200703. PMID 12903677. S2CID 31405929.
  4. ^ Bencini L, Moraldi L, Bartolini I, Coratti A (January 2016). "Esophageal surgery in minimally invasive era". World J Gastrointest Surg. 8 (1): 52–64. doi:10.4240/wjgs.v8.i1.52. PMC 4724588. PMID 26843913.
  5. ^ Nesheiwat, Zeid; Antunes, Catiele (2023), "Zenker Diverticulum", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID 29763172, retrieved 2023-11-07
  6. ^ Sen, P; Bhattacharyya, AK (August 2004). "Endoscopic stapling of pharyngeal pouch". J Laryngol Otol. 118 (8): 601–6. doi:10.1258/0022215041917817. PMID 15453934. S2CID 32002606.
  7. ^ Chang, CY; Payyapilli, RJ; Scher, RL (June 2003). "Endoscopic staple diverticulostomy for Zenker's diverticulum: review of literature and experience in 159 consecutive cases". Laryngoscope. 113 (6): 957–65. doi:10.1097/00005537-200306000-00009. PMID 12782805. S2CID 6206165.
  8. ^ Altman, JI; Genden, EM; Moche, J (May 2005). "Fiberoptic endoscopic-assisted diverticulotomy: A novel technique for the management of Zenker's diverticulum". Ann. Otol. Rhinol. Laryngol. 114 (5): 347–51. doi:10.1177/000348940511400503. PMID 15966520. S2CID 39747386.
  9. ^ Miller, FR; Bartley, J; Otto, RA (September 2006). "The endoscopic management of Zenker diverticulum: CO2 laser versus endoscopic stapling". Laryngoscope. 116 (9): 1608–11. doi:10.1097/01.mlg.0000233508.06499.41. PMID 16954989. S2CID 45791555.
  10. ^ Siddiq, MA; Sood, S; Strachan, D (August 2001). "Pharyngeal pouch (Zenker's diverticulum)". Postgraduate Medical Journal. 77 (910): 506–11. doi:10.1136/pmj.77.910.506. PMC 1742115. PMID 11470929.
[edit]
Retrieved from "https://en.wikipedia.org/enwiki/w/index.php?title=Zenker%27s_diverticulum&oldid=1184016444"