It is an outpouching of the esophagus lined by all three layers, including mucosa, submucosa, and muscularis mucosa. Diagnosis is by barium swallow and upper endoscopy.
| Type | Features |
| Zenker’s diverticula | Pulsion or pharyngoesophageal diverticula; most common; seen in elderly; usually posterior; cricopharyngeal motor dysfunction; Killian triangle weakening; presents with halitosis, regurgitation of undigested food, aspiration pneumonia, dysphagia from pressure, palpable neck mass; squamous cell carcinoma can occur |
| Traction diverticula | Midesophageal; due to TB, scarring from lye, alkali etc., motor dysfunction; typically asymptomatic |
| Epiphrenic diverticula | Located just above diaphragm and LES; due to incoordination between peristalsis and LES relaxation; presents like Zenker’s diverticulum; life threatening hemorrhage may occur |
Hiatal hernia: It is the herniation of part of the stomach through the esophageal hiatus of the diaphragm. It may be asymptomatic or present with heartburn and regurgitation of food and gastric juices, which is worse with bending forward and in the supine position. Hematemesis, dysphagia, and recurrent respiratory infections may occur. Long-standing cases may develop esophageal adenocarcinoma.
Hiatal hernias may be sliding or paraesophageal.
Sliding (axial or esophago-gastric) hernias are more common. They are caused by migration (sliding) of the gastro-esophageal junction above the diaphragm and into the posterior mediastinum due to increased laxity of the phreno-esophageal ligament.
Paraesophageal (rolling or non-axial) hernia is a true herniation through a defect in the pleuroperitoneal membrane or due to incomplete development of the right crus of the diaphragm. Hiatal hernias are often accompanied by GERD. It is located to the right side of the esophagus. The LES may remain in its normal anatomical position or may herniate into the thoracic cavity. Strangulation and volvulus may occur in a paraesophageal hernia.
Barium swallow, video-esophagram, esophagogastroduodenoscopy, and manometry (double pressure peak at LES in paraesophageal type) are done to evaluate symptoms.
Treatment is with antacids, PPIs, lifestyle modifications, or laparoscopic fundoplication (Nissen or Toupet). Surgery is the preferred therapy for symptomatic cases of paraesophageal hernia.
Mallory-Weiss syndrome: It is a mucosal tear or laceration of the distal esophagus near the gastro-esophageal junction. It is preceded by severe vomiting, hiccups, trauma, straining, CPR, or esophagitis. Alcoholics are at higher risk.
It presents with hematemesis of coffee-grounds colored blood, abdominal pain, retching, and vomiting. Severe cases may develop shock.
Diagnosis is based on clinical features, history, and endoscopy. Most cases respond to supportive therapy. Electrocoagulation or cauterization can stop bleeding. Balloon tamponade, intra-arterial vasopressin, or embolization into the left gastric artery may be used in selected cases.
Rupture of esophagus or Boerhaave syndrome: It is total perforation or rupture of the esophagus caused by a sudden rise in intraluminal pressure. It has a high mortality rate.
It clinically presents with severe and repeated vomiting, often after a very heavy meal, trauma, or invasive procedures, followed by excruciating chest pain, dyspnea, and cardiorespiratory collapse.
Subcutaneous and mediastinal emphysema is present, which gives a positive “Hamman’s sign” (crackling sounds are heard with every heart sound). Pleural effusion develops, which has a low pH and high amylase content.
Plain CxR may reveal subcutaneous and/or mediastinal emphysema, mediastinal widening, pleural effusion, pneumothorax, hydrothorax, and intrathoracic air-fluid levels. Gastrograffin swallow or CT scan can be done for confirmation.
Supportive therapy, endoscopic stenting, or surgical repair with open thoracotomy or video assisted thoracoscopic surgery may help.
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