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Diverticulosis and Its Complications in the Foregut and Small Bowel

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Diverticulosis and Its Complications in the Foregut and Small Bowel 9 Review Article Page 1 of 9 Diverticulosis and its complications in the foregut and small bowel Simon Roh1, Yulia N. Matveeva2, John Keech3, Kalpaj Parekh3, Evgeny V. Arshava3 1Department of Radiology, St. Luke’s University Health Network, Bethlehem, PA, USA; 2Department of Family Medicine, 3Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA Contributions: (I) Conception and design: S Roh, EV Arshava; (II) Administrative support: EV Arshava, K Parekh; (III) Provision of study materials or patients: EV Arshava, K Parekh; (IV) Collection and assembly of data: S Roh, YN Matveeva, EV Arshava; (V) Data analysis and interpretation: All authors; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors. Correspondence to: Evgeny V. Arshava, MD. Division of Cardiothoracic Surgery, Department of Surgery, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52242, USA. Email: [email protected]. Abstract: Diverticulosis of the foregut and small bowel is uncommon. In this article we provide an overview of various types of esophageal, gastric, and small bowel diverticula. Asymptomatic diverticula are usually found incidentally during imaging or encountered during unrelated procedures and managed conservatively by observation. Symptomatic patients with esophageal diverticula typically present with dysphagia, regurgitation, and aspiration. These symptoms should prompt elective work-up and treatment. Esophageal diverticulum should be a differential diagnosis for dysphagia, and necessary precaution should be taken during endoscopy to prevent inadvertent perforation. Ideally, patients with dysphagia should be evaluated with imaging prior to endoscopy. Spontaneous perforation and bleeding are very rare, and erosive perforation tends to occur secondary to midesophageal traction diverticula. Gastric, duodenal, and small bowel diverticulosis is frequently asymptomatic. Symptomatic cases may present with obstruction, perforation, and bleeding. While endoluminal techniques have be recently utilized for the management of pharyngoesophageal (Zenker’s) diverticulum, other symptomatic and complicated diverticula of the foregut and small bowel required operative treatment. The complications may be life-threatening and require urgent surgical interventions. Keywords: Diverticulosis; esophagus; foregut; small bowel Received: 25 March 2020; Accepted: 10 July 2020; Published: 25 May 2021. doi: 10.21037/ccts-20-62 View this article at: http://dx.doi.org/10.21037/ccts-20-62 Introduction Manifestations of diverticular disease may vary range from a completely asymptomatic state to medically Based on embryologic development and vascular anatomy, treated illness to life-threatening conditions requiring the alimentary tract is divided into the foregut (mouth to surgery. “Diverticulosis” indicates merely the presence proximal duodenum), midgut (which comprises the distal duodenum, the entire small bowel, and extends to the distal of these outpouchings even without complications. third of the transverse colon), and hindgut. “Diverticulitis,” on the other hand, means inflammatory Diverticulum is an abnormal focal protrusion or bulge complications involving these bulges. Other complications, of the area of wall of the digestive tract. Broadly, diverticula such as bleeding and obstruction, may be associated with of the gastrointestinal tract can be classified as congenital diverticular disease as well. Complications of diverticular or acquired. Pathologically, the wall of the true diverticula disease that may require elective or urgent surgical is formed by all layers of the structure they originate from. treatment frequently develop in a previously asymptomatic False diverticula are only formed by the mucosal layer. patient and should be promptly diagnosed. © Current Challenges in Thoracic Surgery. All rights reserved. Curr Chall Thorac Surg 2021;3:15 | http://dx.doi.org/10.21037/ccts-20-62 Page 2 of 9 Current Challenges in Thoracic Surgery, 2021 of the foregut and small bowel and management of their complications are discussed here. Esophagus Pharyngoesophageal (Zenker’s) diverticulum Zenker’s diverticulum is a diverticulum of the cervical esophagus always located at the level of the pharynx through the Killian’s triangle, bordered by the thyropharyngeus and cricopharyngeus of inferior pharyngeal constrictor muscles. It develops due to hypertonic dysfunction of the cricopharyngeal muscle (1). This condition is seen most commonly in elderly males (2). Pathophysiology Figure 1 Esophagram showing Zenker’s diverticulum (arrow) in The cricopharyngeus of the inferior pharyngeal constrictor a 75-year-old male presenting with dysphagia, who subsequently muscle fails to relax, resulting in increased intraluminal underwent uneventful diverticulectomy and myotomy. pressures proximal to the obstruction, which results in protrusion of mucosa and submucosa through the esophageal wall (3). Clinical presentation and diagnosis Esophageal lumen Patients with Zenker’s diverticulum may present with dysphagia, regurgitation, aspiration, coughing, choking, reflux, and voice changes (3-5). The work- up in elderly patients with such symptoms should start with an esophagram (Figure 1). Proceeding directly with esophagoscopy may pose the risk of diverticulum perforation if this pathology is not considered by the Perforated diverticulum endoscopist prior to the procedure (Figure 2). Figure 2 Intraoperative endoscopic image of the a 67-year-old Treatment patient with an iatrogenic perforation of Zenker’s diverticulum Treatment is indicated for all symptomatic patients. requiring urgent repair. The patient initially presented with Small asymptomatic pharyngoesophageal diverticula dysphagia, but the esophagram was not obtained and the presence found incidentally can be carefully observed. Treatment of diverticulum was not suspected prior to initial endoscopy, which focuses on relieving the pressure distal to the resulted in perforation (courtesy of Rami El Abiad, MD). diverticulum through cricopharyngeal myotomy. Surgical management includes endoscopic diverticulotomy versus operative myotomy with or without diverticulectomy Diverticulosis of the colon is very common, especially or diverticulopexy (5). The two main modalities in endoscopic treatment are carbon dioxide laser and stapler- in the Western world, and it will not be discussed here. assisted techniques (5,6). Endoscopic management has Diverticulosis of the foregut and small bowel are relatively gained popularity because it is minimally invasive and uncommon conditions. Various diverticular conditions the patient population with this condition is typically © Current Challenges in Thoracic Surgery. All rights reserved. Curr Chall Thorac Surg 2021;3:15 | http://dx.doi.org/10.21037/ccts-20-62 Current Challenges in Thoracic Surgery, 2021 Page 3 of 9 Large Zenker’s diverticulum Thyroid Trachea Carotid sheath Esophagus Figure 3 Intraoperative photograph demonstrating a large Zenker’s diverticulum and the expected extent of cricopharyngeal Figure 5 Esophagram showing esophagobronchial fistula (arrow) myotomy (arrow). secondary to erosion of the histoplasmosis necrotizing granuloma into a traction diverticulum in a 43-year-old male. of granulomatous (histoplasmosis or tuberculosis) changes of the mediastinal lymph nodes, creates focal traction on the esophageal wall (3). Clinical presentation and diagnosis These traction diverticula are usually small. Patients are usually asymptomatic and diagnosed incidentally during an imaging examination such as an esophagram obtained for other reasons (3). These diverticula are difficult to see on endoscopy (Figure 4). Over time, ongoing inflammation Figure 4 Flexible esophagoscopy demonstrating traction midesophageal diverticulum (arrow) secondary to granulomatous may result in full-thickness erosion through the esophageal inflammation in an adjacent mediastinal lymph node in a 20-year- wall with resulting esophagobronchial fistulas (Figure 5), old patient with histoplasmosis. mediastinitis, and other complications. Treatment elderly with likely multiple medical comorbidities (3). Small, incidentally found diverticula may be observed. Both open surgery and endoscopic management are In cases of large diverticula, a diverticulectomy or considered safe and effective (1,2,7). Endoscopic management diverticulotomy may be performed. An esophagogastric offers shorter operative time and hospital stay; however, myotomy may be performed with diverticulectomy similar time to initiation of oral diet can be achieved in both to decrease the risk of staple line leak (3). There endoscopically treated and open surgery patients (2,4,5). The remains controversy regarding surgical management of durability of repair is higher among patients undergoing asymptomatic patients with small diverticula (8). open surgery with myotomy (Figure 3) (1,4). Pulsion diverticula Traction diverticula of the esophagus Pulsion diverticulum is a false diverticulum that results Pathophysiology from increased intraluminal pressure and that causes the Traction diverticulum is a true diverticulum in the mid- mucosal and submucosal layers to protrude through a focal esophagus that may develop due to adjacent inflammatory area of the esophageal wall (8). Pulsion diverticula occur in changes (8). Inflammation, most commonly of in the form the midthoracic and distal esophageal regions. Most pulsion © Current Challenges in Thoracic Surgery. All rights reserved.
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