This patient presents with halitosis, dysphagia, regurgitation of undigested food, and imaging showing contrast material in a diverticulum, most consistent with a Zenker's diverticulum.
Zenker's diverticulum (ZD) is a condition caused by cricopharyngeal muscle dysfunction causing increased luminal pressure and characterized by a false diverticula of the esophagus. In ZD, only the mucosa is involved in the herniation. ZD is usually located at the junction of the pharynx and esophagus, at an area of weakness. Symptoms classically include dysphagia, regurgitation, choking, a palpable neck mass, and halitosis. Barium swallow esophagram is usually utilized in the work-up, and will show a collection of dye posterior to esophagus.
Ahuja et al. discussed the pathophysiology of ZD. ZD results from an increased intraluminal pressure within the esophagus. This increased pressure is caused by dysfunction of the cricopharyngeal muscle. Interestingly, dysfunction of this same muscle has been linked to GERD. Regurgitation of partially digested food should alert the clinician to the possibility of cricopharyngeal muscle dysfunction and of the presence of a ZD.
Bizzotto et al. discusses the epidemiology of ZD. ZD typically presents in middle-aged up through elderly individuals. It is most common in the 7th or 8th decades of life, and is more common in males than females. The overall estimated prevalence is between 0.01 and 0.11%. Many ZD's may go undiagnosed if they remain clinically silent.
Figure A depicts a radiograph showing a collection of contrast material in a ZD. Illustration A is a cartoon depicting the anatomical location of a ZD. Illustration B depicts the appearance of a swallow study for a patient with ZD. Not the appearance of the retained contrast material in the diverticulum. For comparison, Illustration C depicts the "bird's beak" finding in achalasia. Finally, video illustration V discusses the clinical presentation and treatment of ZD.
Answer 1: Achalasia typically presents with the "Bird's beak" finding on esophagram.
Answers 3 and 4: Squamous esophageal cancer and esophageal adenocarcinoma do not present with diverticula on esophagram.
Answer 5: Diffuse esophageal spasm is diagnosed doing barometric studies of the esophagus, and does not present with diverticula on esophagram.
Ahuja V, Yencha MW, Lassen LF. Head and neck manifestations of gastroesophageal reflux disease. Am Fam Physician. 1999 Sep 1;60(3):873-80, 885-6.
PMID:10498113 (Link to Abstract)
Bizzotto A, Iacopini F, Landi R, Costamagna G. Zenker's diverticulum: exploring treatment options. Acta Otorhinolaryngol Ital. 2013 Aug;33(4):219-29.
PMID:24043908 (Link to Abstract)