Teaching Case

A 70-year-old male patient presented to an appointment at the gastroenterology outpatient clinic with a history of regurgitation and weight loss. He denied other relevant accompanying symptoms, such as dysphagia.

The barium swallow revealed an oesophagal outpouching filled with barium near the gastro-oesophagal junction, with a smooth rounded contour and a wide neck connecting it to the left oesophagal wall. Additionally, the examination showed stasis of barium in the oesophagal lumen and the presence of prominent tertiary contractions, findings that are compatible with oesophagal dysmotility.

Oesophagal diverticula are outpouchings from the oesophagus. [1] They may be classified by their mechanism of formation into pulsion or traction diverticula, the first being the most frequent type. [2]

Pulsion diverticula result from increased intraluminal oesophagal pressure due to oesophagal dysmotility. They tend to have a rounded contour and a wide neck. These are considered false diverticula because they contain no muscle layer in their wall and remain filled after the oesophagus empties. [1, 3]

Traction diverticula are caused by fibrosis in periesophageal soft tissues, usually resulting from scarring related to granulomatous pathology in perihilar or subcarinal lymph nodes, being more common in the midesophagus. They are most frequently solitary, tented, or triangular in shape. Unlike pulsion diverticula, they contain all layers of the oesophagal wall and tend to empty when the oesophagus collapses. These are considered true diverticula. [3]

Diverticula may also be classified by location. The most common locations are the pharyngoesophageal junction (Zenker's diverticulum), the midesophagus and the distal oesophagus (epiphrenic diverticulum). [1]

An epiphrenic diverticulum is an uncommon form of an oesophagal diverticulum, which occurs in the setting of underlying oesophagal motility disorders, such as diffuse oesophagal spasm and achalasia. These are pulsion diverticula and are located in the distal oesophagus, within 10 cm above the gastroesophageal junction. [1] They are usually solitary and located on the right side of the oesophagal wall in about 70% of the patients. [4] However, patients may occasionally have a diverticulum arising from the left or even multiple diverticula. [1]

In most cases patients are asymptomatic and the diverticulum is an incidental finding. [1] Nevertheless, it may cause symptoms if it is large. [1,3] Dysphagia, regurgitation, chest pain, weight loss and recurrent pulmonary infection due to aspiration account for some of the symptoms patients can experience. Complications such as bleeding, perforation, and malignant transformation are infrequent. [4]

Imaging has an important role in the diagnosis of oesophagal pathology. The barium swallow is the best imaging method to detect oesophagal diverticula and determine their location, type, and size. One of the strengths of the barium swallow in the evaluation of epiphrenic diverticula in particular, is that it depicts the gastroesophageal junction and makes it possible to distinguish between an epiphrenic diverticulum and a hiatal hernia. [3] Additionally, it aids in determining the dysmotility's cause, which is crucial for treatment planning. Other useful diagnostic studies include endoscopy and manometry.  [4]

Generally, treatment is conservative, but when symptoms are severe or intractable, surgical intervention may be necessary. Surgical options include diverticulectomy and esophagomyotomy. [1]

Written informed patient consent for publication has been obtained.