Esophagus diverticulum

Diverticulum of the esophagus can be represented as an outgrowth or protrusion from the outside of the main tube, repeating the anatomical structure of the wall and having its own cavity. The disease was first described by the pathologist Ludlow in 1764. The appendix has a blind end. During the pathology localization of the diverticulum and its influence on adjacent organs and tissues is important. Inflammation in the zone of protrusion is called diverticulitis.

Statistics

According to the frequency, the diverticula of the thoracic esophagus are 20 times higher than that of the cervical and abdominal parts. The total prevalence is 40% of all digestive system diverticula. At x-ray examination pathology is found in 2% of individuals.

Most often, the esophageal diverticulum manifests as a single formation (90% of cases), but in 1/10 of the patients multiple protrusions are detected. It is established that men are more often sick after fifty years of age, suffering from chronic diseases of the digestive system (gastritis, peptic ulcer, pathology of bile ducts).

There are 3 sites of localization of diverticula (4 - subdiaphragmatic space)

Features of the esophagus affecting the course of diverticulitis

The upper border of the thoracic esophagus is the conditional line of the second thoracic vertebra from the side of the posterior mediastinum (space surrounding the heart). Lower - coincides with the esophageal opening of the diaphragm. The entire segment has an adult length of 16-18 cm. From the spine, it is separated by a thin layer of fat.

Tightly in contact with the inner leaf of the pleura (mediastinal area). Passing from the top down, the esophagus is first to the left of the trachea, then passes the aorta and unpaired vein, at the level of the fourth thoracic vertebra is located next to the left main bronchus and the bifurcation of the trachea.

Here, the left atrium of the heart and the pericardial wall adjoin the esophagus in front, the aortic arch, the subclavian artery. Throughout the course of the esophagus is accompanied by a recurrent nerve, multiple groups of lymph nodes. Close proximity to the important organs of the chest leads to their damage in the diverticula of the esophagus.

Causes

By origin, the diverticula of the esophagus are divided into congenital and acquired. The congenital formation is formed in connection with the violation of the formation of the layers of the wall of the esophageal tube. In a certain area there is not enough dense muscle tissue, which does not withstand the load and leads to protrusion.

The process of formation of diverticula is also called diverticulosis. Acquired diverticula develop due to the inflammatory processes in neighboring organs (lungs, pleura, pericardium) and in the esophagus, injuries. Diverticula appear with a long current:

• esophagitis;
• mediastinitis;
• gastroesophageal reflux disease;
• fungal infection;
• tuberculosis of regional lymph nodes;
• esophagospasm;
• akhalasia;
• cicatricial narrowing of the esophagus.

The mechanism of protrusion formation can be pulsion, traction, or mixed.

• Pulsatory diverticulum is always associated with dysfunction of esophageal wall motility, spastic contractions of the muscular layer, and subsequent increase in intra-esophageal pressure. This leads to stretching and protrusion in the weakest place.
• The traction mechanism is caused by fusion and abnormal fixation of the esophageal wall to the inflamed lymph nodes of the mediastinum region. As a result, the muscle layer is stretched, then protrudes.

Diagnosis and treatment of pathology deals with a surgeon

Classification of diverticulums

Depending on the morphological structure of the wall diverticula divide:

• on false (pseudodiverticles) - there is no muscular membrane in the zone of prolapse, in fact, they do not differ from hernias, they always have the acquired character, usually formless, the traction mechanism is involved in the origin, proceed against the background of adhesive-scarring deformations in the zone of inflammation or neoplasm;
• true - correspond to the structure of the esophagus wall, more often congenital, are caused by the formation in the embryonic period of similarity of the cyst.

Pseudodiverticals include any cavities (abscesses, cysts, neoplasms) that break out of neighboring tissues into the esophagus. Typical cases (pseudodivertic Bischoff), caused by lesion of the esophagus wall with a pharyngeal abscess, suppuration of a branchioma tumor, are described.

Localization distinguishes diverticula:

• pharyngeal-esophageal (pharyngo-esophageal, borderline, Zenker diverticula, transitional, cervical);
• bifurcation (epibronchial, parabronchial, upper thoracic);
• supra-diaphragmatic (epiphrenic, inferior thoracic).

Since topographical location causes peculiarities of manifestation and differences in approaches to treatment, we give a separate description of each form.

Features of the pharyngeal esophageal diverticula

The species is found most rarely (3-5% of all cases). By the mechanism of education refer to the pulsed. These include 75% of all pulseless diverticula in the esophagus. Men are 3 times more common than women. Surgeons believe that this is facilitated by the large size of the larynx and pharynx.

Localization on the posterior wall of the pharynx and esophagus is characteristic. Here an anatomical weak spot is formed between the muscular tufts (the Killian triangle). Uncoordinated abbreviations with simultaneous mechanical pressure of the lump of food form in the zone a protrusion outwardly in the form of a sac.

This species is distinguished by very slow growth

Sizes range from cherry to giant. Inside the diverticulum, the body and neck are distinguished, they are lined with a mucous membrane, they can accumulate depending on the size to a liter of liquid. Symptoms of Zenker's esophagus diverticulum depend on the magnitude. It is accepted to divide them into 3 stages. In the first stage, all the symptoms are fickle, the disturbances are only functional, nonspecific.

The patient complains of periodic signs:

• sore throat;
• a change in salivation, causing dry mouth, or, conversely, the accumulation of saliva;
• coughing;
• unpleasant sensations when swallowing;
• "A lump in the throat" amidst excitement or eating.

Patients have long been treated for pharyngitis. Upon examination, the doctor observes the tenderness and tension of the masticatory muscle (Pottenger's symptom). In the second stage, clinical manifestations are caused by stagnant phenomena of mucus, food particles, air in the cavity of the diverticulum. The general condition of the patient is not violated, it is considered satisfactory.

A close examination shows an asymmetrical thickening on the neck, soft protrusion disappears when palpation, but grows against the background of food intake. If a person ate a liquid dish, then the tapping is accompanied by a sound of splashing, at a palpation rumbling is felt. Auscultation reveals a characteristic bubbling.

Pressure on neighboring organs provokes additional symptoms (compression syndrome):

• cough at night;
• change voice timbre;
• shortness of breath;
• In the morning, patients find mucus on the pillow.

It is considered characteristic after eating the development of an attack: face flushes, suffocation, dizziness until fainting. Improvement occurs after vomiting. The stage of decompensation - the patient's condition suffers, the person is losing weight, all the symptoms are very pronounced, complications appear.

A person experiences difficulties in swallowing liquid and solid foods

What is the difference between bifurcation diverticula?

Bifurcation localization in the structure of diverticula of the esophagus takes from 70 to 80%. They are more common in women aged 40-60 years. On the mechanism of traction or mixed, pure pulsion are very rare. If the size does not reach 2 cm in diameter, then the patients do not feel any discomfort.

With larger sizes, the narrowed neck often causes inflammation, so symptoms are manifested: chest pain or epigastric pain, irradiation in the back, difficulty swallowing, regurgitation, bad breath, fever. Pain is considered a mandatory (absolute) symptom of diverticulitis.

Features of epiphrenic diverticula

By origin - pulsion, are located more often in the supra-diaphragm segment of the abdominal part of the esophagus. The frequency of detection in the structure of diverticula - from 10 to 15%. The most cases were found among women of the age group of 50-60 years, in 2/3 it is combined with cardiospasm.

It is believed that the formation is attended by weaknesses in the lower segments of the esophageal tube, uncoordinated contraction of the muscles of the cardia of the stomach and esophagus, increased pressure inside the esophagus, hernia of the esophageal aperture of the diaphragm. The morphological structure of the wall contains all layers of the esophagus. Most often protruding front or left lateral divisions.

Do not reach large sizes (usually no more than 2-3 cm). Thus, ½ cases are detected at the examination and proceed asymptomatically. Symptoms of large diverticula are caused by irritation of the vagus nerve, pressure on the anterior wall of the esophagus.

Among the symptoms:

• difficulty in swallowing;
• weight at the bottom of the sternum;
• feeling of "stuck lump";
• nausea;
• increased regurgitation;
• putrid odor from the mouth.

At considerable sizes, the following are possible:

• pain in the heart;
• cardiopalmus;
• dyspnea;
• manifestation of "gurgling" in epigastrium.

Diagnostics

The most accessible method is aimed tomographic examination of the esophagus by an X-ray apparatus. It allows you to take pictures at different depths, to reveal signs of a diverticulum, to establish the form, the sizes, an angle of a deviation of a neck, presence of an inflammation.

Contrasting allows to reveal the protrusion of the esophagus wall

With large diverticula in the overview picture, cavities with a level of fluid and air are visible, and a message can be traced to the esophagus. Bifurcation diverticula are well detected at small sizes, since they usually have a wide entrance and are clearly contrasted.

In the case of traction, examination may be required with contrast in the horizontal position of the patient. A sign of diverticulitis is a delay of contrast in time for 2 minutes or more, revealing the stratification of the contents of the body of protrusion. Computer tomography - gives more accurate results, is performed with contrast and without it.

Esophagoscopy - allows you to inspect all departments of the esophagus, reveal changes in the walls, signs of inflammation. With fibrogastroscopy, you can notice gastroesophageal reflux (reverse throw food from the stomach), identify diseases that caused the diverticulum, take the material for a biopsy. The procedure is carried out with caution, since there is a risk of perforation of the wall.

Esophageal manometry is used to study the contractile function of the muscles of the esophagus. In differential diagnosis it is necessary to distinguish with the pathology of the heart, therefore electrocardiography, holter monitoring is needed.

What is the complication of diverticulitis?

Inflammation of the diverticulum with a prolonged course can lead to:

• to attacks of suffocation;
• phlegmon of the neck;
• chronic bronchitis;
• aspiration pneumonia, lung abscess;
• bleeding;
• abscessing of the diverticulum;
• erosion of the mucosa;
• perforation in surrounding tissues;
• mediastinitis with esophageal-mediastinal fistula;
• polyps of the esophagus;
• cancerous degeneration.

Treatment of esophageal diverticulum

The choice of treatment depends on the size of the diverticulum, the risk of complications. At small forms and satisfactory state of health of the patient, observation and conservative therapy in the gastroenterologist is recommended. A diet based on the maximum sparing of the esophagus mucosa is important.

It is recommended to abandon dense food, fried foods, pickles, alcohol, spicy seasonings, very hot and cold drinks, cook enough crushed dishes, semi-liquid, boiled, steamed, steamed, puree, take small meals, chew, chew well.

After each meal, it is advised to take measures to completely empty the diverticular bag. For this:

• drink water, compote, jelly, milk;
• strain several times;
• take a profitable position for drainage.

To prevent leakage at night, sleep better on a high pillow. Surgical treatment consists in removing large diverticula. It is indicated if there is or a high risk of complications, severe symptoms. Under convenient conditions, small size diverticulum is immersed in the lumen of the esophagus (by the type of hernia repair), the wall is sutured without plastic.

The operation includes excision of the bag (diverticuloectomy) followed by the plasty of the wall defect with a flap of diaphragm or pleural leaf

Traditional methods of treatment

Folk remedies can significantly help to stop the growth of diverticulum with its small size. To do this, it is recommended to "wash" the esophagus for the night. It consists in drinking warm boiled water, then bending the trunk and vomiting with a cough. From medicinal herbs prepare a decoction, herbal tea and drink it twice a day. Suitable camomile, dog rose, dill seed, motherwort. Therapeutic decoctions must be taken within a month.

Forecast

After the operation, the diverticulum disappears, the long-term results are good. The patient does not feel unpleasant symptoms. Control studies should be conducted at least once a year, as there is a risk of tumor growth.

The detection of the esophageal diverticulum in the compensated stage allows to prevent inflammation and subsequent complications. The appearance of one of the symptoms requires a doctor and a complete examination.