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Posterior Diverticulum with the neck
originating at a site proximal to the Upper
esophageal sphincter
First described by Ludlow in 1767, named for
Zenker and von Ziemssen who reviewed the
world literature in 1877
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Annual incidence of 2 per 100,000
Usually present in age >60
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Often age >75
Male predominance
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Unclear reason for this
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Etiology not entirely clear:
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Increased pressures while swallowing, leading to
outpouching through naturally weak area of
esophagus (Killian’s triangle)
 Resistance to swallowing due to abnormalities of the
UES
 High association with dysphagia (even after repair)
 Acid induced esphageal dysmotility
 Associated with Barrett’s esophagus in 15-20%
 Associated with increased rate of Hiatal Hernia
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Halitosis
Regurgitation of undigested food eaten up to
48 hours prior
Cough
Dysphagia
Aspiration
Gurgling in the throat
Appearance of a neck mass
Chronically: Severe cachexia, recurrent
Pneumonias
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Usually diagnosed with Barium Study
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Entire first glass of barrium can fit in diverticulum if
large and may be confused with esophageal
obstruction
Second diverticulum present in 1-2%
May miss small diverticulum if superimposed in
plane with barium column
 Helps to rotate the patient during exam to avoid this
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Endoscopy
Less often used due to possibility of perforation,
however this is rare
 May find retained pills, food, saliva.
 Must use a forward viewing scope to avoid
perforation
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 Side viewing scopes should be passed over a wire after
direct forward visualization
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Manometry
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Rarely required in patients with Zenker’s
May help with determining pathogenesis of the
diverticulum
 Associated condidtions
 Achalasia
 Esophageal dysmotility
 Increased pharyngeal pressures during swallowing
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Mainstay of treatement is surgical
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Open resection
 Cricopharyngeal myotomy with diverticulectomy
 Cricopharyngeal myotomy without diverticulectomy
 One stage excision
 2 stage mobilization and then excision at later stage.
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Endoscopic
 Cutting through the common wall of the diverticulum
and esophagus
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Aspiration Pneumonia
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And all of the complications of pneumonia
Carcinoma of the diverticulum
Ulceration and bleeding of diverticulum if
retained aspirin
Perforation of diverticulum
Pneumomediastinum
 Mediastinitis
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Severe malnutrition – cachexia
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Our patient’s main presentation was that of
respiratory distress and cachexia.
For all intents and purposes he presented the
same way one would expect Advanced Lung
cancer to present.
Only later did the dysphagia and regurgitation
come to light.
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Harrison’s internal Medicine pg. 1854
Up to Date – article on Zenker’s Diverticulum
van Overbeek JJ. Pathogenesis and methods of
treatment of Zenker’s diverticulum. Ann Otol
Rhinol Laryngol 2003;112:583-593.