Esophageal Diverticulum

What is an esophageal diverticulum?

An esophageal diverticulum is an outpouching or pocket that develops on the inside of your esophagus. Your esophagus is the muscular swallowing tube that connects your mouth to your stomach. Your esophagus has a mucous lining, similar to the rest of your gastrointestinal (GI) tract. Esophageal diverticula (plural) occur in weak spots in your esophageal lining. They protrude outward, forming little caverns.

What are the different types of esophageal diverticulum?

Esophageal diverticula (plural of diverticulum) are either “true” or “false”. A true diverticulum protrudes through all the layers of your esophageal wall, including the muscle. A false diverticulum only protrudes through some of the layers of the wall (the mucosa and submucosa). Providers also identify esophageal diverticula by their location in your esophagus. Diverticula in different regions tend to have different types of causes.

For example:

• Zenker diverticulum. Zenker diverticula are the most common type of esophageal diverticula. They occur at the top of your esophagus, close to where your mouth or throat meets your esophagus. These are usually false diverticula. They’re related to swallowing difficulties, which put pressure on the inside walls.
• Killian-Jamieson diverticulum. This less-common esophageal diverticulum occurs in your cervical esophagus, which runs parallel to your cervical spine in your neck. It’s also called a cervical diverticulum. It’s usually a single, smaller, false diverticulum. This particular type may be due to a congenital (present at birth) weakness in the tissues in that region.
• Midesophageal diverticulum. These true diverticula occur in the middle region of your esophagus, which runs through your chest. They’re also called thoracic diverticula, which refers to your thoracic (chest) cavity. Sometimes they’re called traction diverticula, which refers to the cause. They happen when an external force applies traction to your esophageal wall.
• Epiphrenic diverticulum. An epiphrenic diverticulum occurs in the end part of your esophagus (distal or anterior esophagus,) which ends at your stomach. Diverticula here are typically shallow, false diverticula caused by pressure — for example, from your esophagus trying to push food into your stomach through a narrowed passageway.

How common are esophageal diverticula?

Esophageal diverticula are rare. They occur in approximately 1% of the population. They mostly occur in people older than 50, and especially after 70. They’re more common in men and people assigned male at birth (AMAB).

What are the symptoms of an esophageal diverticulum?

Esophageal diverticula often cause no symptoms. You might not ever know that you have one. Zenker diverticula are the type most likely to cause symptoms. If they do, you might notice:

• A tickle in your throat that makes you cough.
• A lump in your throat when you swallow.
• Feeling like food is stuck in your throat.
• Regurgitation of food when you bend over or lie down.
• Unexplained bad breath.
• Unexplained wheezing.

What causes an esophageal diverticulum?

There are two types of causes — pulsion and traction. Most esophageal diverticula are pulsion diverticula. Pulsion means pushing: Something is repeatedly pushing against the wall of your esophagus in one place. This usually happens when you’re swallowing food. Esophageal disorders that cause difficulty swallowing can create abnormal pressure inside your esophagus when you swallow.

Some of these include:

• Achalasia.
• Esophageal spasms.
• Esophageal strictures.
• Eosinophilic esophagitis.

Traction diverticula occur when something applies traction to your esophagus wall and pulls against it from the outside. This creates true diverticula, indentations through the full thickness of the esophageal wall. Traction diverticula typically occur in your midesophageal or thoracic region, when swelling in your chest causes tissues to stick to your esophagus and then pull back.

Swelling in this region (mediastinitis) is often caused by an infection, such as:

• Tuberculosis.
• Histoplasmosis (a fungal infection).

Pulsion and traction diverticula are both acquired diverticula, which means they develop during your lifetime. Rarely, some esophageal diverticula may be present at birth. In other cases, a congenital weakness in your esophageal tissues in one region may make it easier to acquire an esophageal diverticulum there. But usually, you won’t develop one unless you have another disorder first.

What are the possible complications of an esophageal diverticulum?

Complications can happen as a diverticulum gradually enlarges over time, which increases the risk of food getting stuck in it. You might feel this as a lump in your throat when you swallow, or it might become infected and sore. Retained food may cause bad breath or a bad taste in your mouth. An infection may cause bleeding or swelling. In severe cases, it may produce a palpable lump in your neck.

Food may also get stuck temporarily and then come out later when you change positions (regurgitation). This can cause coughing, choking or irritation. If it happens at night when you’re asleep, it’s possible to accidentally inhale the piece of food (silent aspiration). This could lead to an infection in your lungs (aspiration pneumonia). This mostly happens with Zenker diverticula.

Is an esophageal diverticulum cancerous or precancerous?

Esophageal cancer (squamous cell carcinoma) has been found in .05% of esophageal diverticula. It’s not clear if this is just an association or if the chronic irritation related to a diverticulum could be a cause.

How is an esophageal diverticulum diagnosed?

Medical exams that look inside your esophagus will reveal an esophageal diverticulum. Since many esophageal diverticula don’t cause symptoms, they’re often discovered accidentally while looking for something else. If you do have symptoms in your esophagus, a healthcare provider will examine it with either radiology or endoscopy. Radiology takes pictures from the outside, while endoscopy goes inside.

What types of tests will I have to diagnose an esophageal diverticulum?

Possible tests include:

• Esophagram. An esophagram is a type of X-ray that takes video images of your esophagus when you swallow (fluoroscopy). It’s also called a barium swallow test. For the test, you’ll swallow a chalky contrast solution called barium that coats the inside of your esophagus. A technician will take live X-ray videos while you swallow.
• Upper endoscopy. An upper endoscopy looks inside your upper gastrointestinal tract with an endoscope, a tiny camera on the end of a long tube. It’s also called an EGD test. The endoscopist passes the endoscope through your mouth and down through your esophagus into your stomach while you’re sedated. The camera projects images onto a computer screen.
• Esophageal manometry test. Your healthcare team might suggest this test to check for swallowing problems, which are often the cause of esophageal diverticula. The test measures the strength of your swallowing muscles as you swallow. It measures them through sensors embedded in a nasogastric tube passed through your esophagus.

What is the treatment for an esophageal diverticulum?

Most esophageal diverticula don’t need treatment. If they don’t cause any symptoms or complications, you can leave them alone. But if a diverticulum does cause symptoms or complications, you can have a procedure to close it or remove it. Physicians have a few different ways of doing this. You may also need treatment for the original disorder that caused your esophageal diverticulum.

How do you fix an esophageal diverticulum?

A physician can fix an esophageal diverticulum by surgery or by endoscopy. Different approaches may be better for different types of diverticula. Your physician will also consider your overall health when considering their approach. For example, endoscopy may be a better option if you want or need a minimally invasive approach. They’ll discuss the risks and benefits of each option with you.

Surgical repair

A surgeon may repair your diverticulum either by cutting it out completely (diverticulectomy) or by suspending and stitching it to the esophageal wall (diverticulopexy). Surgical repair may also include a myotomy. Myotomy means cutting into one of your esophageal muscles to relieve excess tension. This may be necessary to address the swallowing disorder involved in your esophageal diverticulum.

Endoscopic diverticulotomy

An alternative approach to surgery is to pass a flexible endoscope through your mouth into your esophagus and operate through the endoscope. This approach is also called a Dohlman procedure. The endoscopist divides the septum (partition) between the diverticulum and the rest of the esophagus wall. They use a laser, electrocautery or stapling device, all of which can both cut and seal the wound.

What is the recovery time after esophageal diverticulum repair?

You may need to stay in the hospital for a day, and then take it easy for a few weeks at home. Your throat may be sore and swollen for a few weeks, which can cause difficulty swallowing. You’ll have instructions on pain relief, though you may not need it. Your physician will advise you on how and when to progress from a liquid diet to a soft diet and finally, to resume your normal diet.

What is the outlook for this condition?

Most people with an esophageal diverticulum will never be bothered by it. But if you are, there are several ways to repair it. The success rate for esophageal repair is over 90%. There’s a 10% risk of complications from the procedure, such as bleeding, infection or injury to your esophagus. Your healthcare team will discuss with you the risks and benefits of different procedures on a case-by-case basis.

A note from Cleveland Clinic

You may develop an esophageal diverticulum, a pouch in your esophageal wall, if you have a condition that causes difficulty swallowing. Abnormal pressure when you swallow can cause your esophagus lining to create a pouch in a weak spot. It might never bother you. But if you start to notice new symptoms in your esophagus, see your healthcare provider. They can help diagnose and treat your diverticulum.