Diagnostic Dilemma

Diagnostic Dilemma

A 65-year-old man with a history of a "bleeding ulcer" 7 years
earlier presents with complaints of progressive dysphagia for solids and
liquids over the past 4 months. The patient states that he has had a 40-pound
weight loss during this time, but denies any fevers, chills, abdominal pain,
melena, or anorexia. He states that recently he cannot go to his favorite
restaurant, as whenever he eats he experiences severe coughing fits. He also
describes regurgitation of undigested materials soon after eating.

The patient’s ulcer history is vague, and he denies ever having had an
endoscopy to evaluate the problem. His review of systems is negative, although
he admits to a 30-pack-year smoking history and to drinking up to 12 oz of
scotch per night for the past 20 years. Vital signs and physical exam are
normal. Routine laboratory evaluation and chest x-ray are within normal limits.
An endoscopy and a barium swallow are performed and are illustrated in Figures
1 and 2.


The correct diagnosis in this patient is:
Esophageal cancer
b. Zenker’s diverticulum
c. Achalasia
d. Peptic stricture

The correct answer is b. Although the patient has a strong history
of smoking and alcohol consumption, which puts him at risk for squamous cell
cancer of the esophagus, and a presentation similar to that seen with
esophageal cancer, achalasia, and peptic strictures, the barium swallow in
this case yields a definitive diagnosis of Zenker’s diverticulum.

Zenker’s diverticula are formed by herniation of the hypopharyngeal
mucosa through an area of weakness in the posterior esophagus. This defect
occurs between the cricopharyngeus and inferior pharyngeal constrictor
muscles in an area known as Killian’s triangle. High intrabolus pressures
after swallowing are thought to contribute to the diverticular formation.[1]

Most patients with Zenker’s diverticulum present after the age of 50,
with the peak incidence actually being in the 7th to 8th decade of life.
Although small diverticula do not change pharyngeal anatomy, progressive
enlargement can cause compression of the upper esophagus. The opening of a
large diverticulum often becomes aligned with the pharynx, favoring the
entry of swallowed material into the diverticulum rather than the esophagus.
If the diverticulum becomes large enough, it can completely obstruct the

Symptoms suggestive of a Zenker’s diverticulum include dysphagia,
regurgitation of undigested material, halitosis, cough, hoarseness,
aspiration, bronchitis, and pneumonia. On physical examination, a large
diverticulum can present as a neck mass, which gurgles while eating.


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