Esophagus Diverticula
intradiverticular Varix

Video Endoscopic Sequence 1 of 4.

intradiverticular Varix, rare endoscopic finding.

A 66-year-old female with hepatic cirrhosis due to prolonged use of of acetaminophen and portal hypertension with tense ascites. Patient has a mild bleeding.

 

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esophagus Diverticulum

Video Endoscopic Sequence 2 of 4.

Patien also has a diverticulum of the upper third

Esophageal diverticulum

Video Endoscopic Sequence 3 of 4.

In the gastroesophageal junction there are esophageal varices. Inside of a diverticulum of a lower third there is a violet structure that may correspond to a varix.




Esophageal diverticulum

Video Endoscopic Sequence 4 of 4.

A third diverticulum observed in the middle third




Endoscopy of Zenker's Diverticulum.

Video Endoscopic Sequence 1 of 8.

Endoscopy of Zenker's Diverticulum.

This 75 year-old male presented with of increasing dysphagia with nocturnal regurgitation of partially digested food material.

Zenker diverticulum is rare, occurs in elderly populations, and results in a classic presentation of symptoms. The condition has severe complications, including aspiration and pneumonia, and is managed by surgical repair. or with endoscopic management.

Pharyngoesophageal diverticulum, also known as Zenker’s diverticulum (ZD), is an acquired disease that is formed by the outpouching of hypopharyngeal mucosa between the inferior pharyngeal constrictor muscle and the cricopharyngeal muscle in an area of junctional muscle weakness known as Killian’s triangle. Its pathophysiology is not well known.

 


Endoscopy of Zenker's Diverticulum.

Video Endoscopic Sequence 2 of 8.

It has some food trapped in it.

In 1877, Friedrich Albert von Zenker, professor of pathology at Erlangen University in Germany, described the pulsion diverticulum that bears his name. His series included 5 personal cases and 22 cases collected from the literature. In the beginning of the 20th century, Killian identified the origin of the diverticulum between the cricopharyngeus muscle and the inferior pharyngeal constrictor muscles. Wheeler first successfully resected this haryngoesophageal diverticulum in 1886.

A Zenker diverticulum, which is seen in the images below, is formed by the herniation of mucosa through an area of weakness in the posterior wall of the hypopharynx (the Killian triangle).

Sometimes Zenker diverticula are called pharyngoesophageal diverticula because of their close proximity to the cervical esophagus; however, this is somewhat of a misnomer because the diverticula actually arise from the hypopharynx rather than from the esophagus. Of the diverticula discussed in this article, Zenker diverticula are the most common type to cause symptoms.

Zenker diverticula are an acquired pulsion-type of diverticula that probably develop because of the aging process. They form in the posterior hypopharynx at a point where a defect in the muscular wall, between the inferior pharyngeal constrictor muscle and the cricopharyngeal sphincter (Killian triangle), usually exists.

Zenker diverticula are believed to occur because of an outflow obstruction caused when loss of coordination of the buccal squirt (ie, swallowing movement of the tongue posteriorly with contraction of the oropharyngeal muscles) and opening of the cricopharyngeus (ie, the upper esophageal sphincter) occurs. The noncompliant cricopharyngeus muscle becomes fibrotic over time.



Endoscopy of Zenker's Diverticulum.

Video Endoscopic Sequence 3 of 8.

Retroflexed image showing the Nasopharynx.

Canalization of the esophagus with Zenker diverticulum is not an easy task, in our patient some, several attempts to bring forward the esophagus was performed, until we succeed in passing an thin endoscope.

Patients present with upper esophageal dysphagia, regurgitation of undigested food, aspiration, noisy deglutition, halitosis, and changes in voice. Mild-to-moderate weight loss is frequent. Aspiration and pneumonia are potentially serious complications. Although the diverticulum can reach sizes of 15 cm or more, it is rarely palpable. Squamous cell carcinoma has been found in the diverticulum in less than 0.5% of specimens. Coexistent hiatal hernia, esophageal spasm, achalasia, and esophagogastroduodenal ulceration are common.


Endoscopy of Zenker's Diverticulum.

Video Endoscopic Sequence 4 of 8.

The septum between the diverticula and the upper sphincter

Endoscopic view of the common wall between the cervical esophagus and the diverticula.

The endoscopic treatment of symptomatic pharyngoesophageal diverticula involves the incision of the septum between the diverticulum and the esophageal lumen, within which the cricopharyngeal muscle is present. Zenker’s diverticulum (ZD) is an uncommon disease, which is typically treated surgically. The alternative to surgery is a diverticulotomy, performed endoscopically. The endoscopic treatment of ZD can achieve the same clinical results as surgical treatment while reducing the incidence of complications and mortality.

The endoscopic intraluminal treatment of ZD by use of a flexible endoscope is nowadays an alternative to surgical treatment. A monopolar forceps or a needle-knife is used to cut the ZD bridge. Argon plasma coagulation (APC) has also been used for this purpose. In order to have a better view during the procedure, devices were developed such a a hood attached to the endoscope and a flexible overtube called a diverticuloscope.



Video Endoscopic Sequence 5 of 8.

To overcome the pressure exerted by the diverticulum in the upper esophageal sphincter, we used a pediatric endoscope to perform the endoscopy with some difficulty the scope is passed into the esophagus, and then slowly withdrawn.












 

 

Endoscopy of Zenker's Diverticulum.

Video Endoscopic Sequence 6 of 8.

The fluoroscopic barium esophagram is the primary tool for the diagnosis of Zenker diverticulum. The diverticulum appears as an outpouching arising from the midline of the posterior wall of the distal pharynx near the pharyngoesophageal junction. This is best identified during swallowing and is best seen on the lateral view, on which the diverticulum is typically noted at the C5-6 level.

 

 

 

 






Endoscopy of Zenker's Diverticulum.

Video Endoscopic Sequence 7 of 8.

Frequently, a posterior bar representing a prominent cricopharyngeus muscle is noted as the contrast bolus passes. As the contrast bolus normally travels quickly through the pharynx and upper esophagus, careful observation during fluoroscopy is necessary, and videofluoroscopy is helpful for documentation purposes.


Endoscopy of Zenker's Diverticulum.

Video Endoscopic Sequence 8 of 8.

When the diverticulum is large enough to protrude laterally, it protrudes to the left in 90% of the cases. After the contrast agent bolus passes the upper esophagus, the diverticulum is typically seen extending posterior to the cricopharyngeus muscle, and contrast material that was trapped within the diverticulum may be regurgitated back into the hypopharynx.

A Valsalva maneuver may be helpful in visualizing the diverticulum after swallowing. Occasionally, a patient may aspirate contrast material from the diverticulum. Pay attention to the lumen of the diverticulum because irregularities or filling defects within the diverticulum may indicate the rare complication of squamous cell carcinoma.






Esophageal Mucosal Bridge.

Video Endoscopic Sequence 1 of 3.

Esophageal Mucosal Bridge.

An 80 year-old female with esophageal mucosal bridge and esophageal diverticula, was found as an incidental finding on a routine endoscopy, two years previously we did not find this image only the diverticula of the middle third.

The mucosal bridge is oriented in the long axis of the esophagus.

Mucosal bridges are classified into congenital and secondary types. Congenital mucosal bridges are rare.

Secondary mucosal bridges have been associated with reflux esophagitis, Barrett’s mucosa sclerotherapy, hematoma, malignant tumors, corrosive esophagitis, drug-induced esophagitis, radiation esophagitis, submucosal dissection (hematoma), systemic lupus erythematosus (SLE), dermatomyositis with esophageal ulcer, Mallory–Weiss syndrome, and candidiasis.


 














Esophageal Mucosal Bridge.

Video Endoscopic Sequence 2 of 3.

Mid Esophageal Diverticulum.

Almost all esophageal diverticula are acquired pulsion diverticula. The most common symptoms are dysphagia, regurgitation, thoracic pain, and pulmonary manifestations related to aspiration.


Mid Esophageal Diverticulum

Video Endoscopic Sequence 3 of 3.

Longitudinal Esophageal Mucosal Bridge and a diverticula.

Mucosal bridges may extend obliquely or horizontally across the esophageal lumen. first such case was reported in 1969 by Dafoe and Ross. More recently, incidental mucosal bridges have often been demonstrated at endoscopy, but only a few patients with symptoms attributable to this disorder have been reported. bridges usually occur in the mid- and lower esophagus.


Mid Esophageal Diverticulum

Video Endoscopic Sequence 1 of 3.

Mid Esophageal Diverticulum

Almost all esophageal diverticula are acquired pulsion diverticula. The most common symptoms are dysphagia, regurgitation, thoracic pain, and pulmonary manifestations related to aspiration.


Mid Esophageal Diverticulum

Video Endoscopic Sequence 2 of 3.

Mid esophageal Diverticulum.

The exact cause of a mid-esophageal diverticulum is not known but the condition has been associated with scarring and various esophageal motor abnormalities.

 

 

Inlet patch of gastric mucosa in upper esophagus

Video Endoscopic Sequence 3 of 3.

Inlet patch of gastric mucosa in upper esophagus

 


 

Zenker's Diverticulum

Zenker's Diverticulum

This 69 year old male, has been complained of dysphagia with nocturnal regurgitation of partially digested food material.

Endoscopy shows the diverticula and the septum

Pharyngeal diverticulae may be posterior, posterolateral, or lateral (pharyngocoele) but the most commonly encountered type is the posterior pulsion diverticulum. There is usually a single opening at Killian's dehiscence, although the presence of a double pharyngeal pouch has been reported.the majority of pharyngeal pouches protrude to the left side and it has been suggested that the handedness of the patient may determine the side on which the pouch occurs.



Zenker´s Diverticula

Zenker´s Diverticula

The radiologic study shows the pharyngoesophageal (Zenker’s) diverticulum.

Esophageal diverticula are more or less pronounced saccular protrusions of the esophageal wall. Traction diverticula (e.g., caused by extrinsic traction) affect the entire wall thickness, while in pulsion diverticula only the mucosa and submucosa protrude through a gap in the muscular wall. There are three sites of predilection for diverticula in the esophagus: cervical diverticula (synonym: Zenker diverticula, comprising approximately 70% of all esophageal diverticula), thoracic diverticula (approximately 22%), and epiphrenic diverticula (approximately 8%).




Esophageal Pseudo-Diverticulum with Submucous fistula

Video Endoscopic Sequence 1 of 5.

Esophageal Pseudo-Diverticulum with Submucous fistula

This a 60 year-old, female who, in a routine endoscopy shows this image, which displays, two pseudivertícum, by passing a savary guide, is determined to be a sub-mucous fistula.





Esophageal Pseudo-Diverticulum with Submucous fistula

Video Endoscopic Sequence 2 of 5.

A Savary guide, is introduced and passed through of the sub-mucous fistula.

Esophageal Pseudo-Diverticulum with Submucous fistula

Video Endoscopic Sequence 3 of 5.

A Savary guide, is introduced and passed through of the sub-mucous fistula.



Esophageal Pseudo-Diverticulum with Submucous fistula

Video Endoscopic Sequence 4 of 5.

The savary guide, which has passed through the lower Pesudo-diverticulum is observed.



Esophageal Pseudo-Diverticulum with Submucous fistula

Video Endoscopic Sequence 5 of 5.

The lower pseudodiverticulum is displayed


















 

 

Esophageal Diverticula

Esophageal Diverticula

Inside of the diverticula a bronchus or blood vessel is displayed.


















 

 

Divertículo Esófago

Mid Esophageal Diverticulum

Thoracic esophageal diverticula are uncommon. They account for less than 30% of esophageal diverticula. The majority of patients are asymptomatic or have minimal symptoms. About one third of patients present with severe symptoms. Occasionally, pulmonary symptoms can be the sole manifestation of the disease and can be life threatening. Dysphagia, food regurgitation, chest pain, weight loss, and reflux symptoms are the most commonly encountered gastrointestinal symptoms. Malignancy is a rare complication of esophageal diverticula; therefore, patients should be educated regarding this complication. Appropriate diagnostic tests should be arranged promptly if alarming symptoms develop. Esophageal motor disorders are found in the majority of patients and need to be taken into account when planning therapy. Medical and endoscopic therapies have limited roles in treatment. Surgery is the standard of care for patients with pulmonary or incapacitating symptoms related to an epiphrenic diverticulum, and myotomy is the cornerstone of surgery. To ensure complete relief of the obstruction, the myotomy should extend distally at least 1.5 to 2 cm into the stomach and proximally at least to the neck of diverticulum. Adding a nonobstructing entireflux procedure is recommended to prevent the development of gastroesophageal reflux disease. Occasionally, a specific treatment such as a diverticulectomy or diverticulopexy needs to be directed to the diverticulum. Preliminary treatment results from minimally invasive surgery, especially laparoscopy, have been promising. In the future with increased experience, minimally invasive surgery may become the standard of care.

 

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