Epiphrenic Diverticulum
An outpouching near the lower end of the esophagus
Quick Facts
- Type: Structural esophageal condition
- Location: Lower esophagus, just above the diaphragm
- Common cause: High pressure from a motility disorder
- Often linked to: Achalasia or esophageal spasm
Overview
An epiphrenic diverticulum is a pouch that forms in the lower portion of the esophagus, just above the diaphragm, which is the muscle separating the chest from the abdomen. The esophageal lining pushes outward through a weak point in the muscular wall, creating a sac that can collect food and liquid.
This type of diverticulum is usually a pulsion diverticulum, meaning it is driven by high pressure inside the esophagus. That pressure most often comes from an underlying swallowing (motility) disorder. Because the pouch and the underlying disorder are linked, evaluation and treatment usually address both at the same time.
Epiphrenic diverticula are uncommon, and their location near the lower esophagus and stomach gives them a distinctive set of symptoms and treatment considerations. Because food and liquid can pool in a pouch at the lowest part of the esophagus, regurgitation and the risk of inhaling food into the lungs can be more noticeable than with pouches higher up. Recognizing and treating the underlying high-pressure problem is central to relieving symptoms and preventing the pouch from returning after treatment.
Symptoms
Symptoms vary widely; small diverticula may cause none, while larger ones can be troublesome. Possible symptoms include:
- Difficulty swallowing, with a sensation of food sticking in the lower chest
- Regurgitation of undigested food, sometimes long after a meal
- Chest pain or pressure
- Heartburn or a sour taste
- Bad breath from trapped food
- Nighttime cough or choking, especially when lying flat
Food retained in a large pouch can be inhaled into the airway during sleep, which may cause repeated chest infections. Symptoms often overlap with those of the underlying motility disorder.
Causes
Epiphrenic diverticula form when pressure builds up inside the lower esophagus, pushing the inner lining out through a weak area of muscle. This raised pressure is usually the result of an esophageal motility disorder in which the muscles fail to relax or contract in a coordinated way.
Underlying conditions commonly associated with epiphrenic diverticula include achalasia, in which the lower esophageal muscle fails to relax, and diffuse esophageal spasm. Because these disorders create persistent high pressure, the diverticulum tends to grow and recur if the underlying problem is not addressed.
Risk Factors
- An underlying esophageal motility disorder, especially achalasia
- Older age
- Long-standing, untreated swallowing difficulty
- A history of high-pressure esophageal contractions on testing
Diagnosis
Diagnosis combines imaging with tests of esophageal function:
- Barium swallow: Shows the size, neck, and position of the pouch as you swallow contrast.
- Upper endoscopy: Lets the doctor inspect the lining and rule out other problems.
- Esophageal manometry: Measures muscle pressure and coordination and is key to identifying the underlying motility disorder.
- CT scan: May be used to plan surgery and assess surrounding structures.
Identifying the underlying motility disorder is essential because it guides treatment.
Treatment
Treatment depends on symptoms and the underlying cause.
- Observation: Small, symptom-free diverticula are often monitored without intervention.
- Surgery: Symptomatic or large diverticula are usually treated surgically. This typically involves removing the pouch (diverticulectomy) along with a myotomy, a procedure that cuts the tight lower esophageal muscle to relieve the high pressure that caused the pouch.
- Anti-reflux procedure: A partial wrap is sometimes added to prevent reflux after the muscle is cut.
Treating both the pouch and the underlying motility disorder reduces the chance of recurrence. Minimally invasive and endoscopic techniques are available in specialized centers.
After surgery, people typically resume eating gradually, beginning with liquids and progressing to soft and then normal foods as healing allows. Follow-up checks that swallowing has improved and that the pouch has not returned. Because the surgery is technically demanding and the condition is rare, it is best performed by surgeons with specific experience in esophageal disorders, who can combine removal of the pouch with the right treatment for the underlying motility problem.
Prevention
- There is no proven way to prevent an epiphrenic diverticulum
- Early diagnosis and treatment of esophageal motility disorders may reduce sustained high pressure
- Eating slowly, chewing well, and avoiding very large meals can ease symptoms
- Staying upright for a while after eating may reduce regurgitation and nighttime aspiration
When to See a Doctor
See a doctor if you have ongoing difficulty swallowing, regurgitation of undigested food, or food sticking in your lower chest. Seek prompt care if you experience:
- Unintended weight loss or an inability to keep food down
- Repeated chest infections or coughing and choking at night
- Severe or persistent chest pain
- Sudden inability to swallow even liquids or saliva
Frequently Asked Questions
What causes an epiphrenic diverticulum?
It usually forms because high pressure inside the lower esophagus pushes the lining out through a weak point in the muscle. That pressure most often comes from an underlying motility disorder such as achalasia or esophageal spasm.
Does an epiphrenic diverticulum always need surgery?
No. Small pouches that cause no symptoms are often simply monitored. Surgery is recommended when the diverticulum is large or causes swallowing problems, regurgitation, or chest infections, and it usually includes treating the underlying muscle disorder.
Why is a muscle-cutting procedure done during surgery?
Because the pouch is caused by high pressure from a tight or uncoordinated esophageal muscle, surgeons often cut that muscle (a myotomy) at the same time as removing the pouch. This relieves the underlying pressure and lowers the risk that the diverticulum returns.
Can an epiphrenic diverticulum cause problems while sleeping?
Yes. A large pouch can hold food and liquid that may be inhaled into the airway when lying flat, causing coughing, choking, or repeated chest infections. Staying upright after meals can help reduce this risk.
How is it diagnosed?
A barium swallow X-ray usually reveals the pouch, and an upper endoscopy lets the doctor view it. Esophageal manometry, which measures muscle pressure, is important for finding the underlying motility disorder that guides treatment.
References
- American College of Gastroenterology. Esophageal motility disorders.
- MedlinePlus, U.S. National Library of Medicine. Esophagus disorders.
- Mayo Clinic. Achalasia.
- National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Digestive diseases.