Epiphrenic Diverticulum

• • Dysphagia and a sensation of pressure in the lower esophagus after eating

  • Intermittent vomiting, substernal pain

  • Typical radiologic contour

  • Disturbed motility of the lower esophagus

  • Associated hiatal hernia on occasion

Epidemiology

• • Usually located in the distal 10 cm of the esophagus but may occur as high as the mid thorax

  • Usually associated with discordinated smooth muscle activity in the distal esophagus, related to acid reflux, underlying achalasia or diffuse esophageal spasm, which results in segmenting contractions and development of a diverticulum

  • Esophagitis may develop at the ostium

  • -Peridiverticular localized mediastinitis may be seen, especially if ulceration of the mucosa occurs

Symptoms and Signs

• • Dysphagia

  • Regurgitation

  • Aspiration

  • Spasm type chest pain

  • Heartburn

Imaging Findings

• • Contrast radiography

  • -Contrast filling of a smooth pouch located in the distal esophagus

    -Distal esophageal narrowing may be observed

  • Manometry: Simultaneous repetitive contractions (or sometimes high-amplitude, prolonged contractions) in the body of the esophagus and in many cases abnormal lower esophageal sphincter function (ie, high resting pressure, incomplete relaxation with swallowing, or an exaggerated postglutition pressure rise)

• • Esophageal manometry should be performed in every case to evaluate underlying motility disorders and to assess lower esophageal sphincter

  • pH monitoring may be added to further evaluate lower esophageal sphincter dysfunction and associated reflux

Rule Out

• • Carcinoma

  • Benign strictures

  • Esophageal webs

  • Achalasia

  • Diffuse esophageal spasm

• • Upper GI contrast radiography with fluoroscopy

  • Esophagoscopy

  • Manometry

  • pH monitoring

When to Admit

• • Aspiration with pneumonitis

  • Perforation with mediastinitis

  • Severe dysphagia prohibiting enteral intake

• • Diverticulectomy and longitudinal myotomy to include the lower esophageal sphincter extending proximally to the level where esophageal function becomes manometrically normal

Surgery

Indications

• • Moderate to severe symptoms

  • A loose fundoplication is added to treat or prevent reflux with division of lower esophageal sphincter

Complications

• • Esophagitis

  • Bleeding from mucosal ulceration

  • Aspiration

  • Perforation

Prognosis

• • Surgery is successful in 80-90% of cases

References