esophagus health

Esophageal diverticula

Definition

Esophageal diverticula are saccular extroflections, similar to pockets or pockets, which form in the wall of the esophagus. The causes that determine its onset include the increase of pressure inside the esophagus, points of weakness of its wall, and scarring phenomena affecting the periesophageal tissues (which surround the esophagus).

The bolus stagnation inside these pockets (diverticula) can give rise to episodes of regurgitation and be associated with complications such as inflammation and / or perforations of the bowel. Diverticula can form at any level of the esophagus, but mainly involve the distal portion of the cervical and thoracic tracts.

The most frequent diverticular manifestation of the esophagus is Zenker's diverticulum .

Classification

There are several ways to classify the diverticula of the esophagus; first of all, they can be congenital (present from birth) or acquired (they can develop in the course of life). Congenital esophageal diverticula often derive from excessive weakness of the esophageal wall, while the acquired forms are distinguished in drive or traction diverticula.

From the histopathological point of view, we can distinguish:

  • true diverticula: they involve all the layers of the esophageal wall (mucosa, submucosa, muscle and adventitia);
  • false diverticula, also known as pseudo-diverticula : they originate from the herniation of the mucosa and submucosa when there is a resistance defect in the muscular wall (example: Zenker diverticulum).

Depending on the location, we can instead distinguish:

  • hypopharyngeal or cervical or pharyngeal-oesophageal diverticula (tract III ° superior of the? esophagus)
  • parabronchial or mediothoracic diverticula (middle stretch III)
  • epiphrenic diverticula (lower segment III)

Anatomy outline: the esophagus

The esophagus is a muscular tube, about 25 cm long, whose primary function is to bring food from the pharynx to the stomach.

The passage of food from the pharynx to the esophagus is regulated by the upper esophageal sphincter (SES), which acts as a barrier to esophageal-pharyngeal reflux and corresponds to a high-pressure zone. The esophagus passes into the mediastinal cavity (located between the trachea and the vertebral column), before crossing the diaphragm (the large muscle that divides the thorax from the abdomen) at the esophageal hiatus. At the lower end of the esophagus is the lower esophageal sphincter (SEI), a smooth muscle ring that regulates the passage of food from the esophagus to the stomach, acting as a barrier to gastroesophageal reflux.

Classification

  • Diverticula of congenital type : from altered esophageal development.
  • Pseudodiverticoli : consequent to the dilation of the glands of the esophageal submucosa. They can appear in single or multiple form. Intramural diverticula are also defined, as they are confined to the wall thickness.
  • Diverticula proper : from drive or traction.
    • Drive diverticulums: they are hernias of the mucosa, which extend through the muscular layers of the esophagus. They are formed following the increased intraluminal pressure associated with abnormal regional peristalsis. They are typically pharyngo-esophageal (for example: Zenker's diverticulum, which is in any case a fake diverticulum) and epiphrenic (caused by dyskinesias such as achalasia, an alteration that causes the progressive loss of esophageal peristalsis).
    • Traction diverticulums : extend to the entire thickness of the esophageal wall. They are mostly middle-thoracic and may be of congenital origin or secondary to fibrous adhesions (scars) produced as a consequence of an inflammatory disease (bronchopneumonia or pulmonary inflammatory processes) that has affected the organs close to the esophagus (especially lymph nodes) .

Epidemiology

Most oesophageal diverticula begins in middle-aged and elderly adults. The presentation of the disease in infants and children rarely occurs.

In particular, Zenker diverticula are typically found in people over the age of fifty.

Cause and effect

Esophageal diverticula can form mainly according to the following mechanisms:

  • structural lesions or altered motility of the esophagus : they usually derive from a weakening of the muscular seal of the esophageal mucosa and are caused by motor abnormalities.

In fact, the structure and motility of the esophagus may not conform to:

    • relaxation of muscle tissue;
    • the lack of coordination at the level of the lower esophageal sphincter;
    • the presence of stenosis (narrowing of the lumen).

The lining of the esophagus, under the pressure of the internal pressure on the organ, can protrude through a weak point of its muscular wall, as in the case of Zenker's diverticulum.

  • adhesions or inflammatory processes : the origin in traction diverticula, usually medium-oesophageal or epiphrenic, is due to the presence of extraluminal extrinsic adhesions, which can cause the esophageal wall to protrude.

In the early stages, the presence of extroflexions in the wall of the esophagus causes only a few swallowing disorders: the swallowed food tends to stop at the level of the diverticulum and the patient has the feeling that there is a foreign body in the throat.

With the progression of the disorder, the affection can increase its size, causing consequences on breathing (it can compress the trachea and cause breathing difficulties).

Finally, serious complications can also arise: in addition to regurgitation, food that gets stuck in the diverticulum can stagnate and infect the wall of the esophagus, causing the perforation of the sac and spreading the infection to neighboring tissues.

Symptoms

To learn more: Esophageal Diverticula Symptoms

Often the patients affected by the disease are asymptomatic. In other cases, the presence of esophageal diverticula can cause:

  • dysphagia (difficulty swallowing, feeling of obstruction);
  • food obstruction (suffocation);
  • symptoms of variable severity related to esophageal dyskinesias;
  • food regurgitations: reappearance of ingested food;
  • chest pain;
  • cough (some foods can be regurgitated in the airways);
  • dyspnea: difficulty breathing or shortness of breath;
  • halitosis: may be present as a secondary consequence of food residues that are blocked at the level of the lesion;
  • noises of gurgling during swallowing;
  • potential infection of the pharyngeal areas due to the foods introduced which accumulate at the level of the diverticulum.

In rare cases, perforation or bleeding of the esophageal diverticulum may occur.

In the event that a Zenker diverticulum reaches large dimensions, it is possible that a palpable swelling on the neck may occur.

Complications

  • Chronic esophagitis;
  • Inflammation;
  • Inhalation pneumonia;
  • Perforation, resulting in mediastinitis or formation of esophagus-tracheo-bronchial fistulas;
  • Hemorrhage;
  • Carcinoma.

Esophageal diverticula: diagnosis and therapy »