Epiphrenic Diverticula (Distal Esophageal Diverticulum)

What is Epiphrenic Diverticula (Distal Esophageal Diverticulum)?

Esophageal diverticulum, an relatively uncommon condition, comes in three types based on its location in the food pipe, or esophagus: proximal (Zenker or phrenoesophageal, making up 70% of cases), middle (thoracic and mediastinal, 10% of cases), or the tail- end of the esophagus (epiphrenic, found in 20% of diagnosed patients). Among these, an epiphrenic diverticulum, also known as a pulsion diverticulum, is an uncommon type of esophageal diverticulum that happens in the last 10 centimeters of the esophagus, most often found 4 to 8 cm above the entrance to the stomach. These diverticula are made up of the internal and underlying lining of the esophagus which push out through a weakness in the muscle layer of the esophagus. This makes them false or pseudo-diverticula. The weak spot in the muscle layer is the entry point for nerves and blood vessels to supply the end of the esophagus.

The surgical options to treat a symptomatic esophageal diverticula change depending upon its exact location. For lower esophageal (epiphrenic) diverticula, surgical strategies have moved from the traditional open chest procedure to the now-favored procedure through the abdomen, made possible through the progression of laparoscopy, a less invasive surgery using a tiny camera. This is likely because it provides a better view of the connection between the stomach and the esophagus during surgery and allows for a simultaneous process called fundoplication, often carried out when patients are also diagnosed with gastroesophageal reflux disease – a condition that causes frequent acid reflux.

What Causes Epiphrenic Diverticula (Distal Esophageal Diverticulum)?

Risk Factors and Frequency for Epiphrenic Diverticula (Distal Esophageal Diverticulum)

Epiphrenic diverticulum of the esophagus is an uncommon condition that largely affects the lower part of the esophagus. The condition is found in around 0.02% to 3% of people, with men and those in their sixties and seventies being slightly more affected. This condition may have no symptoms, or it can cause complications like esophagitis (inflammation of the esophagus), bleeding from ulcers, the gathering and steadfastness of food in the esophagus with vomiting. These symptoms are similar to those seen in achalasia or other conditions that affect the muscles of the esophagus. However, such symptoms are usually due to an underlying issue affecting the muscles of the esophagus rather than the diverticulum (pouch) itself, regardless of the size of the diverticulum.

There is also a link between this condition and a type of cancer known as squamous cell carcinoma. However, the chance of this type of cancer developing in patients with an epiphrenic diverticulum is quite rare, happening in about 0.6% of cases. Those most likely to be affected are men (making up 83% of cases), people of an older age (average age being 68), and those with larger diverticula (greater than 5 cm in size).

Signs and Symptoms of Epiphrenic Diverticula (Distal Esophageal Diverticulum)

Epiphrenic diverticula are pocket-like areas that develop in the esophagus, and their effects may vary based on their size and if there’s a concurrent condition affecting the movement of the esophagus. An esophageal epiphrenic diverticulum can cause difficulty swallowing, bringing up food or drink, heartburn, issues with breathing, and pain behind the breastbone when swallowing. Small diverticula without any associated movement disorder can go unnoticed and might be accidentally discovered during other health screenings. However, if the diverticulum is large or paired with a motility disorder, it can cause worsening difficulty swallowing and regurgitation – these are the two most common symptoms.

Some people might experience chest pain, heartburn, coughing at night, and symptoms similar to asthma. There are also concerning symptoms like weight loss, a lung infection due to aspirating food or drink into the lungs, vomiting blood, passing black, tar-like stools, and painful swallowing. These symptoms could potentially indicate that the diverticulum has transformed into esophageal cancer, which is a malignant condition. As the diverticulum grows, complications may arise, such as severe heartburn caused by food stasis (food remaining in the esophagus for too long) or compression of nearby structures like the esophagus, lung, or heart.

Testing for Epiphrenic Diverticula (Distal Esophageal Diverticulum)

If your doctor suspects you might have an epiphrenic diverticulum, which is a pouch or sac-like protrusion in the wall of your esophagus, they might have to do several tests. These tests help determine the size, location, and other characteristics of the diverticulum as well as if there are any movement problems in your esophagus. By doing these tests, your doctor can better plan for potential surgeries and treatments.

The tests usually involve a barium swallow, an esophagogastroduodenoscopy (EGD), and a procedure called manometry. A barium swallow is a test where you swallow a liquid called barium that shows up on medical images, which can help your doctor see the anatomy of your esophagus more clearly. This test can pinpoint the location and size of the diverticulum, check the muscle movements (known as motility) of your esophagus, and find any blockages or abnormal growths. Most people only have one diverticulum and it’s usually on the right side of the esophagus, but some people might have multiple diverticula.

An EGD is a procedure where a thin instrument with a light and camera, called an endoscope, is passed down your throat to take a look at the inside of your esophagus. It helps check for ulcers, inflammation, cancer, and a condition called hiatal hernia (where part of your stomach pushes up through your diaphragm). The test is quite accurate at confirming an epiphrenic diverticulum, getting it right about 91% of the time.

Manometry is important for testing the muscle functions of the esophagus. It looks for any disorders that cause abnormal muscle movements in your esophagus. This is necessary to confirm the presence of a muscle movement disorder.

If you also have symptoms of acid reflux, your doctor may also want to monitor your stomach acid levels to see if the reflux is due to a diverticulum or another problem. However, some experts believe that manometry and pH monitoring, the test for stomach acid levels, aren’t always necessary because they’re often used based on the assumption that a problem with muscle movement in the esophagus is always present.

Treatment Options for Epiphrenic Diverticula (Distal Esophageal Diverticulum)

There’s no universal agreement on the best surgical approach for treating a condition called epiphrenic diverticula. In the past, surgeons typically used a technique called thoracotomy. However, advances in technology have seen a shift towards a less invasive option – the laparoscopic transhiatal approach. This method involves making small incisions and using a laparoscope, a thin tube with a camera, to guide the surgery. While it has several benefits, there are also potential challenges, such as being unable to clearly see the upper part of the diverticulum (a small bulge in the esophagus) or coming across surprise adhesions – areas where tissues have stuck together. In these cases, a sudden switch to the traditional thoracotomy approach may be necessary, and this can require significant changes in the patient’s position and the use of different anesthesia techniques. Also, sometimes this approach leads to an incomplete procedure and complications can occur in up to 45% of cases. Therefore, surgeons need to carefully plan ahead and consider the best approach.

Indications for surgery are based on symptoms rather than the size of the diverticulum. So, surgeries are recommended if you show symptoms like worsening difficulty swallowing, regurgitation of food, trapped food, or more severe complications like pneumonia due to aspiration (inhaling food or drink into the lungs), perforation (tearing of the esophagus), and in rare cases, cancer. If you don’t show any symptoms, your epiphrenic diverticulum can be managed without surgery.

Surgery can be performed through traditional (open) or minimally invasive (laparoscopic/robotic) techniques. Open surgery includes laparotomy and left thoracotomy, or a blend of thoracic and abdominal surgery. Minimally invasive surgeries can be performed through the abdomen or chest, depending on the diverticulum’s position relative to the lower esophageal sphincter – the muscle at the end of the esophagus. Robotic-assisted devices, like the Da Vinci Surgical System, may also be used to enhance visualization and accuracy.

Another important factor to consider is the high likelihood of a motility disorder, where the muscles and nerves in the esophagus don’t work as they should, resulting in problems swallowing. To address this, surgeons usually perform an additional procedure known as a myotomy, which involves cutting the muscles in the esophagus to relieve the obstruction. If not done, this could lead to the reoccurrence of diverticula in around 20% of cases or leak rates approaching 24%.

Surgeons also pay careful attention to the extent of the myotomy, especially in the area beneath the diverticulum. After the procedure, a partial wrapping of the stomach or fundoplication is usually performed to prevent backflow of stomach acid that can cause heartburn, a condition seen in 48% of untreated patients as opposed to 9.5% of patients having undergone the fundoplication.

What else can Epiphrenic Diverticula (Distal Esophageal Diverticulum) be?

If someone has an epiphrenic diverticulum, they might experience various symptoms. It may feel similar to other health conditions, making it hard to figure out the exact problem. People might confuse it with other throat pouches, like Zenker and traction diverticula, but a specific x-ray test called a barium esophagogram can spot the difference based on where they are located in the throat.

These symptoms can also be found in many throat movement disorders, which might be the real cause of the pouch. Tests that measure the pressure inside the esophagus, known as manometric studies, can help doctors decide what to do.

Several other conditions could also be to blame for the symptoms like heartburn, a hiatal hernia (where part of the stomach pushes up into the chest), benign (non-cancerous) tumors, and throat cancer. Doctors can rule these out using standard tests, including the esophagogram, an upper GI endoscopy (EGD), and manometry.

What to expect with Epiphrenic Diverticula (Distal Esophageal Diverticulum)

Epiphrenic diverticula, which are small pouches near the bottom of the esophagus, often don’t cause symptoms and can usually be managed with non-surgical treatments. Only about 10% of patients experience complications or symptoms. However, if surgery is necessary, studies have shown that it can resolve symptoms in roughly 90% of cases. This is particularly true when the surgical removal of the pouch (diverticulectomy) is combined with a procedure to cut the muscles of the esophagus (myotomy).

Possible Complications When Diagnosed with Epiphrenic Diverticula (Distal Esophageal Diverticulum)

Epiphrenic diverticula is a condition that can cause problems on its own, as well as during its treatment. Large diverticula, or pockets, can lead to issues like regurgitating food, food getting stuck, or accidentally inhaling food into the lungs. Though less common, other problems could include ulcers, internal scarring called adhesions, abscesses or pockets of pus, abnormal connections called fistulas, bleeding, breaking open or tearing, and even turning into cancer. No matter how rare these complications are, it’s very important to thoroughly check for them before managing the diverticulum.

After treatment, complications could include leaking from the suture line or missed injuries in the mucous lining during the procedure. Difficulty swallowing may result from an incomplete procedure or too tight wrap, and acid reflux could occur. The most common issue after surgery is a suture line leak in between 5% and 37% of patients. Factors increasing the risk of leaks include using multiple staple cartridges, having a wide opening at the base of the diverticulum, and having a location in the mediastinum or middle section of the chest.

Other After-Surgery Effects:

• Complication rates range from 5.3% to 50%
• Death rates can be up to 9%
• Leak rate of 16.6%
• About 70% of surgeries are successful
• In 21% of cases, symptoms remain the same
• In 8% of cases, symptoms become worse
• Acid reflux may occur in up to 60% of patients, but may be alleviated by using a partial wrap around the base of the esophagus, called a fundoplication
• Over a 22-month follow-up, patients can achieve successful results

Preventing Epiphrenic Diverticula (Distal Esophageal Diverticulum)

If you’re dealing with a medical condition called an epiphrenic diverticulum, it’s important for you to recognize the different signs and symptoms of this disease. There are certain warning signs you should be aware of that might indicate a serious condition, such as the breaking or tearing (perforation) of an organ, or cancer (malignancy). If you don’t have any symptoms, it’s still crucial that you tell healthcare workers about your condition and stay on the lookout for any potential symptoms.

Epiphrenic diverticulum is a pouch that forms in the lower part of your esophagus, which is the tube connecting your throat and stomach. It’s important to also avoid blind esophageal intubation, a procedure that involves inserting a tube down your throat without the aid of a visual tool. This is to prevent possible injuries such as perforation or tearing of the diverticulum, which can occur if the procedure is not performed correctly.