The Anatomy of Esophageal Diverticulum

An esophageal diverticulum is a pouch, or sac, that protrudes outwards from the wall of the esophagus, the tube in which food passes from the mouth to the stomach. "Esophageal diverticulum" refers to a single pouch, and "esophageal diverticula" refers to multiple pouches. It is a rare disease that affects less than 1% of the population.

Esophageal diverticula may be present from birth, but they can also develop later in a person's life.

This article will discuss the anatomy of esophageal diverticula, symptoms, and treatment options.

Anatomy

Esophageal diverticula aresacs that protrude from the esophageal wall. The esophagus is the tube that connects the mouth to the stomach. Esophageal diverticula protrude in parts of the lining of the esophagus that are weak. This can happen anywhere along the esophagus.

The pouches found in esophageal diverticula can have a diameter of up to 4 inches. In some people, there are a number of smaller diverticula found all the way along the esophagus.

Location

The sacs found in espophageal diverticula can appear anywhere on the esophagus. Esophageal diverticula are classified differently based on where they are located along the esophagus and include:

• Zenker's diverticula: These are esophageal diverticula found in the top area of the esophagus.
• Mid-esophageal diverticula: Pouches occur in the middle of the esophagus.
• Ephiphrenic diverticula: Pouches occur at the base of the esophagus.

Most commonly, the pouches are found in people who are middle-aged or older.

Anatomical Variations

Esophageal diverticula can form in a variety of ways.

Traction Diverticula

An esophageal diverticulum known as a traction diverticulum occurs when there is an external force on the wall of the esophagus that creates the pouch. This most commonly occurs in the middle area of the esophagus.

Pulsion Diverticula

Also referred to as epiphanic diverticula, these pouches occur in the lower part of the esophagus. This happens when the esophagus is being pushed due to incoordination of the sphincter muscle in the lower esophagus. The sphincter is a ring made of muscle that helps connect the esophagus with the stomach.

Zenker's Diverticulum

Occurring in the top part of the esophagus, a Zenker's diverticulum is caused by abnormal tightening of the upper esophageal sphincter between the lower pharynx (throat) and the upper esophagus. This causes a bulge to form, and over time pressure will cause a diverticulum to develop. This is the most common type of esophageal diverticulum.

Causes

Esophageal diverticula can be congenital (present at the time of birth) but can also form later in life.

Generally, esophageal diverticula form either due to pressure from outside the esophagus, from an infection or inflammation in the chest, or when there is pressure inside the esophagus when eating.

The most common cause of esophageal diverticula is a motility disorder, when muscles involved in digestion stop working properly.

Motility disorders can stop the muscles of the esophagus from properly working and from effectively moving food from the mouth to the stomach. These include:

• Esophageal scleroderma (hardening or tightening of the esophagus)
• Achalasia (a condition in which nerves in the esophagus are damaged)

These disorders may also cause esophageal diverticula:

• Esophagitis, an inflammation of the lining of the esophagus
• Disorders of the sphincter in the upper or lower parts of the esophagus
• Weakness in the walls of the esophagus

Clinical Significance

Most people who have esophageal diverticula are asymptomatic and may never receive a diagnosis of the condition until symptoms appear or the sacs are noticed in imaging tests for another condition.

People with esophageal diverticula often don't receive treatment unless the symptoms experienced are severe. In this case, surgery may be performed to remove the pouches.

Diagnosis

Many people with esophageal diverticula will never receive a diagnosis as they are asymptomatic.

If a person experiences symptoms, a doctor will take a medical history, do a physical exam, and may conduct tests to reach a diagnosis.

Possible tests for esophageal diverticula include:

• Barium swallow/esophagram: With this test, you'll be asked to drink a chalky liquid that contains barium before an X-ray. The barium coats the wall of the esophagus and provides contrast so the esophagus and any growths will be easily seen on an X-ray.
• Fiberoptic endoscopic evaluation of swallowing (FEES): During this test, a long tube with a light and camera attached to it called an endoscope is inserted into the esophagus through the mouth. The doctor can use the endoscope to look at the esophagus and take samples of tissue.

Symptoms

Symptoms are often present when an esophageal diverticulum is more than 5 centimeters in width.

Esophageal diverticula can cause symptoms that can range from mild to severe. These include:

• Pain with swallowing (odynophagia)
• Trouble swallowing (dysphagia)
• Heartburn
• Feelings of food stuck in the throat
• Chronic cough
• Chest pain
• Bad breath
• Aspiration pneumonia
• Regurgitation (partly digested food traveling up the throat from the stomach)

As the pouches associated with esophageal diverticulum stretch over time, symptoms may worsen.

Complications

In some people, the irritation in the esophagus can increase the risk of cancer of the esophagus.

In rare cases, an esophageal diverticulum may result in an abnormal connection forming between the esophagus and the respiratory tract (an anomaly called a bronchoesophageal fistula). A 2017 study reported of there being fewer than 50 known cases of this occurring.

Other possible complications of esophageal diverticula include:

• Perforation of the esophagus
• Obstruction of the esophagus
• Squamous cell carcinoma (cancer of the cells that line the surface of the esophagus)

Treatment

If a person has esophageal diverticula but no symptoms, the pouches are left alone. Your healthcare provider will carefully monitor their growth and check in on your symptoms.

But for those who do experience symptoms, surgical and therapeutic options are available. Surgical options include:

• Surgery to remove the diverticula, either laparoscopically or via open surgery
• Myotomy surgery, in which the esophageal sphincter muscle is cut through laparoscopically to open up the sphincter.

Nonsurgical options include:

• Eating bland foods
• Chewing carefully
• Taking small bites
• Drinking water during and after meals
• Sitting totally upright when eating