Diverticula of the esophagus

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.

Diverticula of the esophagus

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, regurgitation of foods and gastric juices that is made worse by bending forward and 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 and are caused by migration or 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 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. LES may remain in it’s 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 for evaluation of 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 by clinical features, history and endoscopy. Most cases respond to supportive therapy. Electro Coagulation or cauterization will 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, 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.