Preeyanka Sundar, MD1, Manasa Sagaram, DO2, Sara Ancello, DO1, Sudhakar Reddy, MD1; 1Mountain Vista Medical Center, Mesa, AZ; 2Arizona College of Osteopathic Medicine, Glendale, AZ
Introduction: Esophageal diverticula are outpouchings from the esophageal lumen that include one or more of the wall layers. Less than 10% of the time, these diverticula are found immediately above the lower esophageal sphincter (LES) and are classified as epiphrenic diverticula. The prevalence of this rare subset is 0.02 to 0.77% while the incidence is 1:500,000 of the general population. This report describes a patient who presented with a rare case of symptomatic large epiphrenic diverticula.
Methods: A Caucasian 74 year-old male, with rheumatoid arthritis and recurrent dysphagia, presented with a food bolus sensation (pork loin) for 1 day, with reported dysphagia a majority of the time. His last esophagogastrodudenoscopy (EGD) was 2 years ago for food bolus removal which showed no diverticula; the food was easily pushed into the stomach. His current lab work was unremarkable. An EGD was done urgently which revealed mild esophagitis, a 3cm hiatal hernia, and gastritis. Interestingly, 2 large distal esophageal diverticular pockets were present proximal to the gastroesophageal junction. On the first pass, the endoscope freely passed into the stomach without obstruction; on re-examination of the esophageal diverticula, a large food bolus was noted within the pocket which was successfully retrieved antegrade with a pentapod. The most proximal diverticulum had several smaller diverticula within it, for a total of 6 diverticula, ranging from 0.5 to 2cm. No strictures or narrowing were noted. The patient clinically improved and was discharged with close outpatient follow up imaging. Discussion: Epiphrenic diverticula are a rare subset of esophageal diverticula, and are also classified as a type of pulsion diverticula. This is similar to Zenker’s diverticula, also classified as a pulsion type, which are much more common and occur in the hypopharynx. Pulsion diverticula occur due to increased pressures in the esophagus secondary to LES dysmotility, strictures, or narrowings, with some studies demonstrating esophageal dysmotility as the cause for 75-100% of epiphrenic diverticula. Patients are generally asymptomatic unless the diverticula are larger than 5cm, and may take several years to form. Perforation is rare but increases slightly with manipulation such as by endoscopic ultrasound or EGD. This case is unique in that not only are epiphrenic diverticula rare to begin with, but they also developed quickly and became symptomatic in the patient all within two years.
Figure 1. Image 1: N duodenum. Image 2: Normal stomach and small retained food in stomach. Image 3-4: View on retroflexion of stomach - hiatal hernia with areas of food impaction. Image 5-6: LA grade A esophagitis. Image 7: mild LA grade A esophagitis, and parts of food stuck to lumen. Images 8-9: severe food bolus impaction within diverticular pocket in distal esophagus seen upon withdrawal examination, esophageal diverticulum pocket with several smaller diverticula inside. Image 10-11: smaller esophageal pouches visible within larger diverticula, seen post aggressive irrigation. Image 12: upper esophageal mucosa appearance normal.
Figure 2. Image 13: Esophageal lumen to the left, large epiphrenic esophageal diverticular pocket to the right, seen post irrigation of food impaction.
Disclosures: Preeyanka Sundar indicated no relevant financial relationships. Manasa Sagaram indicated no relevant financial relationships. Sara Ancello indicated no relevant financial relationships. Sudhakar Reddy indicated no relevant financial relationships.