Diverticula of the esophagus are rare, accounting for &lt;1% of all barium gastrointestinal radiographs and &lt;5% of all cases ofdysphagia. Here, we report a case of an 80-year-old male presented with the chief complaint of dysphagia for 8 months. Contraststudies with barium swallow and computed tomography (CT) scan were performed to diagnose the etiology behind dysphagia, andit turned out to be a case of esophageal diverticulum which demonstrates outpouching from the wall of the esophagus in bariumswallow and CT scan. These investigating modalities also aid in eliminating other causes of dysphagia

Deepthi, Bekal Tharanath

Seetha Pramila, Varada Venkata

Tyagi, Varsha

English

Atharva Scientific Publications (E-Jounals)

Vol 4 | Issue 3 | May - Jun 2018 Indian J Case Reports 242
Case Report
A rare case of esophageal diverticulum with classical presentation
Bekal Tharanath Deepthi, Varada Venkata Seetha Pramila, Varsha Tyagi
From Professor, Department of Radiodiagnosis, Rajarajeswari Medical College, Bengaluru, Karnataka, India
Correspondence to: Dr. Varada Venkata Seetha Pramila, Prof. Department of Radiodiagnosis, Rajarajeswari Medical College, 
Bengaluru, Karnataka, India. E-mail: varadaseetha@gmail.com
Received – 13 April 2018 Initial Review – 17 May 2018 Published Online – 28 June 2018
An esophageal diverticulum is a sac that protrudes from the esophageal wall. Esophageal diverticula are rare findings that have an estimated incidence of 1:500,000 per year and 
a prevalence of 0.015–2%. Since Ludlow, in 1764, first described 
a diverticulum of the esophagus, many contributions have been 
made as to topography, classification, etiology, and treatment. 
In 1877, Zenker and Von Ziemissen made a careful study of the 
subject, classifying diverticula as of the pulsion and traction types.
Esophageal diverticula can be classified in many ways. 
They can be divided into congenital and acquired based on the 
origin, into pulsion and traction based on the etiology, or into 
false or true based on the histology, but the simplest and most 
practical way is to classify them according to anatomy, into 
four categories: Zenker’s (hypopharyngeal) diverticula, mid-
esophageal diverticula, epiphrenic diverticula, and intramural 
pseudodiverticulosis [1].
Although majority of the patients complain of dysphagia or 
other obvious manifestations of esophageal dysfunction, it is also 
important to consider other esophageal diseases in older patients 
with a history of recurrent bronchitis or pneumonitis. We report a 
case of an 80-year-old male presented with the chief complaint of 
dysphagia for 8 months.
CASE REPORT
An 80-year-old male patient presented with a complaint of 
dysphagia since eight months, which was insidious in onset and 
gradually progressive. Difficulty in swallowing was found to be 
more with solids than liquids. There was a history of regurgitation 
of solid foods, after which the discomfort reduced. There was 
no history of a cough or loss of weight. There was no history 
of tuberculosis in the past. There were no other complaints 
suggestive of any mediastinal mass.
On general examination, his pulse rate was 88 bpm and 
blood pressure was 120/80 mmHg. On systemic examination, 
cardiovascular, respiratory, gastrointestinal, and central nervous 
systems were within normal limits. The patient was clinically 
diagnosed to have esophageal diverticulum/achalasia. Considering 
the patient’s age, esophageal carcinoma was also considered 
in the differential diagnosis. The patient was initially treated 
symptomatically, and the patient was subjected to investigations 
to further confirm the diagnosis.
Complete blood counts, serum electrolytes, liver function tests, 
and renal function tests were within normal limits. On barium 
swallow, there was a large contrast-filled sac in the thoracic 
esophagus (Fig. 1). On contrast-enhanced computed tomography 
(CECT) scan, contrast-filled extraluminal outpouching was 
noted arising from the left lateral wall of esophagus measuring 
3.3 cm × 2.4 cm × 1.9 cm, which was 5.6 cm proximal to the 
gastroesophageal junction with the neck of the sac, measuring 
2.8 cm extending from T5 to T7 thoracic vertebrae (Figs. 2 and 3).
Our case was planned for conservative management initially, 
but as the patient had a relapse of the symptoms in 2 months, 
a video-assisted thoracic esophageal diverticulectomy was 
performed. The patient had complete relief of symptoms following 
the procedure.
DISCUSSION
A diverticulum (plural: Diverticula) is the medical or biological 
term for an outpouching of a hollow (or a fluid-filled) structure 
in the body. Three categories of diverticula are recognized, 
namely pharyngoesophageal, parabronchial, and epiphrenic [2]. 
An esophageal diverticulum is a pouch that protrudes outward 
from the weak portion of the esophageal lining. This pocket-like 
structure can appear anywhere in the esophageal lining between 
ABSTRACT
Diverticula of the esophagus are rare, accounting for <1% of all barium gastrointestinal radiographs and <5% of all cases of 
dysphagia. Here, we report a case of an 80-year-old male presented with the chief complaint of dysphagia for 8 months. Contrast 
studies with barium swallow and computed tomography (CT) scan were performed to diagnose the etiology behind dysphagia, and 
it turned out to be a case of esophageal diverticulum which demonstrates outpouching from the wall of the esophagus in barium 
swallow and CT scan. These investigating modalities also aid in eliminating other causes of dysphagia.
Key words: Barium swallow, Contrast computed tomography, Diverticulum, Dysphagia, Esophagus
Deepthi et al. A rare case of esophageal diverticulum 
Vol 4 | Issue 3 | May - Jun 2018 Indian J Case Reports 243
the throat and stomach. There are several areas of structural 
weakness in the wall of the pharynx and esophagus, where either 
there are gaps in the muscular walls or the thin strip-like muscles 
are relatively unsupported by surrounding neck tissue. Transient 
protrusions through these areas of weaknesses are termed 
pouches, while persistent protrusions are called diverticula [3,4].
Esophageal diverticula are rare findings that have an estimated 
incidence of 1:500,000 per year and a prevalence of 0.015–2%. 
Most esophageal diverticula, which are present in older adults, 
are acquired lesions. The average patient age at diagnosis is 
60–70 years old, and there is a male predominance with a 
Figure 3: Three-dimensional reconstructed computed tomography 
image demonstrates contrast-filled extraluminal outpouching 
arising from the left lateral wall of the esophagus (arrow)
Figure 1: Anteroposterior (a) and lateral (b) films of barium swallow 
demonstrates large contrast-filled sac in the thoracic esophagus 
(arrows)
ba
Figure 2: (a and b) Axial and coronal section of computed tomography 
shows extraluminal outpouching arising from the left lateral wall of 
the esophagus (arrows)
ba
male-female ratio of around 2–3:1 [5]. The etiology, symptoms, 
and therapeutic requirements suggest a categorization in three 
forms: Pharyngoesophageal (Zenker diverticula), parabronchial, 
and epiphrenic diverticula.
The pathophysiology of the epiphrenic diverticulum is still 
unclear. The herniation of the mucosa and submucosa through a 
defect in the muscular layer is probably caused by a longstanding 
impairment of the esophageal motor activity. However, the 
associated motor disorder is not always recognized and diagnosed. 
Typical symptoms include dysphagia, regurgitation of undigested 
food, borborygmi in the cervical region, chronic coughing, 
aspiration due to overspill, halitosis, and weight loss [6-8].
Our case came with the classical presentation with typical 
symptoms and age of presentation, and the diagnosis was 
confirmed by barium swallow and contrast CT studies and was 
initially planned for conservative management, but due to failure 
to obtain symptomatic relief, a surgical approach was carried out. 
The diagnosis of the esophageal diverticulum is done by simple 
barium swallow normally revealing the diverticulum. It may 
also be found with upper GI endoscopy or CT with oral contrast. 
A barium swallow is the prime diagnostic tool; evaluation of 
the diverticulum, associated esophageal abnormalities, and 
complications are assessed by a barium swallow. Esophagoscopy 
adds little to the evaluation of the diverticulum but may be 
indicated in the assessment of other esophageal abnormalities. 
Motility studies, which may be difficult or hazardous to perform, 
are of little use in the diagnosis and treatment of Zenker’s 
diverticula. Manometric evaluation of mid-thoracic or epiphrenic 
diverticula usually shows an associated motility disorder and may 
influence treatment decisions [9].
Some reports were described by Killian-Jamieson on 
diverticula being detected on ultrasonography of the thyroid 
gland [10]. Due to the proximity of the upper esophagus to 
the thyroid gland, pharyngoesophageal diverticula may mimic 
thyroid nodules on thyroid ultrasonography [11]. A Zenker 
diverticulum reportedly can be distinguished from a thyroid 
nodule on ultrasound by the sign of air in the diverticulum. 
The treatment of esophageal diverticula must be based on the 
pathophysiology and natural history of the disease; asymptomatic 
diverticula do not need a specific treatment, small diverticula 
may be left in place and not resected, medium-size diverticula 
may be either treated by diverticulectomy, diverticulopexy, 
or esophagodiverticulostomy in case of pharyngoesophageal 
diverticula, resection is probably the ideal therapy for larger 
diverticula, and a myotomy should always be included to the 
procedure [12].
CONCLUSION
Although our case came with the classical clinical presentation of 
an esophageal diverticulum, other causes had to be ruled out due 
to the rare occurrence of this condition. However, through barium 
studies and CT as imaging modalities, the diagnosis was firmly 
established. Barium swallow and CECT are non-invasive and the 
modalities of choice for diagnosing esophageal diverticulum.
Deepthi et al. A rare case of esophageal diverticulum 
Vol 4 | Issue 3 | May - Jun 2018 Indian J Case Reports 244
REFERENCES
1. Achkar E. Esophageal diverticula. Gastroenterol Hepatol (N Y) 
2008;4:691-3.
2. Khan N, Ismail F, Van de Werke IE. Oesophageal pouches and diverticula: 
A pictorial review: General Surgery. S Afr J Surg 2012;50:71-5.
3. Nelson AR. Congenital true esophageal diverticulum: Report of a 
case unassociated with other esophagotracheal abnormality. Ann Surg 
1957;145:258.
4. Rubesin SE. The pharynx. Structural disorders. Radiol Clin N Am 
1994;32:1083-101.
5. Tse CS, Parikh ND. An uncommon source of upper gastrointestinal bleeding: 
Epiphrenic esophageal diverticulum. Gastroenterol Rep (Oxf) 2017;5:313-5.
6. Siddiq MA, Sood S, Strachan D. Pharyngeal pouch (zenker’s diverticulum). 
Postgrad Med J 2001;77:506-11.
7. Tobin RW. Esophageal rings, webs, and diverticula. J Clin Gastroenterol 
1998;27:285-95.
8. Borrie J, Wilson RL. Oesophageal diverticula: Principles of management 
and appraisal of classification. Thorax 1980;35:759-67.
9. Baker ME, Zuccaro G Jr, Achkar E, Rice TW. Esophageal diverticula: 
Patient assessment. Semin Thorac Cardiovasc Surg 1999;11:326-36.
10. Kim HK, Lee JI, Jang HW, Bae SY, Lee JH, Kim YS, et al. Characteristics 
of Killian-Jamieson diverticula mimicking a thyroid nodule. Head Neck 
2012;34:599-603.
11. Pang JC, Chong S, Na HI, Kim YS, Park SJ, Kwon GY. Killian-Jamieson 
diverticulum mimicking a suspicious thyroid nodule: Sonographic diagnosis. 
J Clin Ultrasound 2009;37:528-30.
12. Herbella FA, Patti MG. Modern pathophysiology and treatment of 
esophageal diverticula. Langenbeck’s Arch Surg 2012;397:29-35.
Funding: None; Conflict of Interest: None Stated.
How to cite this article: Deepthi BT, Seetha VVP, Tyagi V. A rare case of 
esophageal diverticulum with classical presentation. Indian J Case Reports. 
2018;4(3):242-244.


A rare case of esophageal diverticulum with classical presentation

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A rare case of esophageal diverticulum with classical presentation

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