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:
a. Esophageal cancer
b. Zenker’s diverticulum
d. Peptic stricture
The correct answer is b. Although the patient has a strong history of smoking and alcohol(Drug information on 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.
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 esophagus.
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.