Kanana Aburayyan, MD1, Dipen Patel, MD, MBA1, Azizullah Beran, MD1, Sami Ghazaleh, MD1, Christian Nehme, MD1, Jordan Burlen, MD1, Mona Hassan, MD2; 1University of Toledo Medical Center, Toledo, OH; 2University of Toledo, Toledo, OH
Introduction: Esophageal diverticulum is a rare condition that results from outpouching of the esophageal wall. It can be divided, based on location, into three types. Zenker’s diverticula are found in the upper third of the esophagus and account for 70% of cases. Epiphrenic diverticula arise in the lower third of the esophagus and account for 20% of the cases. Mid-esophageal diverticula are the least common and account for 10% of the cases. When symptomatic, the main symptoms are dysphagia, regurgitation, halitosis and chronic cough. In this case, we present a rare case of gastrointestinal bleeding from epiphrenic diverticulum
Methods: A 77-year-old male with a past medical history significant for atrial fibrillation on Rivaroxaban who presented with complaints of hematemesis and melena of one day duration. Vital signs were stable and physical examination was unremarkable. Lab work showed hemoglobin of 6.6 mg/dl, INR of 2.4, and an aPTT of 42 seconds. He underwent EGD which showed a large mid-esophageal diverticulum with blood clots and ulcerated mucosa (Figure 1). Chest CT scan with oral contrast 9 cm esophageal diverticulum along the right side of the distal esophagus (Figure 2a and b). Surgery was felt to be technically difficult and the patient was managed conservatively. The patient’s hematemesis resolved gradually and his hemoglobin stabilized. Discussion: Epinephric diverticulum is a rare medical entity. It’s a false, pulsion diverticulum that result from outpouching of the submucosal and mucosal layers of the esophageal wall due to increased intraluminal pressure. Usually epiphrenic diverticula are asymptomatic. When symptomatic, presentations include epigastric pain, regurgitation, dysphagia and weight loss. Epiphrenic diverticulum presenting with upper GI bleeding is very rare with only 9 case reports identified in our literature review. It’s postulated that diverticular mucosal ulceration results from incomplete emptying of food from the diverticula. This causes irritation of the diverticular mucosa with subsequent GI bleeding.
Figure 1:endoscopic images of distal esophagus showing huge epiphrenic esophageal diverticulum with blood clots and ulcerated mucosa.
figure 2a: Cross sectional view of chest CT scan with oral contrast showing 9 cm epiphrenic diverticulum.
figure 2b: chest CT scan with oral contrast showing 9 cm epiphrenic diverticulum.
Disclosures: Kanana Aburayyan indicated no relevant financial relationships. Dipen Patel indicated no relevant financial relationships. Azizullah Beran indicated no relevant financial relationships. Sami Ghazaleh indicated no relevant financial relationships. Christian Nehme indicated no relevant financial relationships. Jordan Burlen indicated no relevant financial relationships. Mona Hassan indicated no relevant financial relationships.