ConditionDigestive system
Epiphrenic Diverticulum
An epiphrenic diverticulum is a pouch that bulges out from the lower esophagus, just above the diaphragm. It is rare and usually develops because of an underlying esophageal motility disorder, such as achalasia or esophageal spasm, that raises pressure inside the esophagus. Many cause no symptoms and are found by chance. Others cause difficulty swallowing, regurgitation of undigested food, chest pain and coughing at night. Symptomatic pouches are treated by addressing the motility problem, often with surgery.
Also called: Distal esophageal diverticulum, lower esophageal diverticulum, pulsion diverticulum of the esophagus
At a glance
- What it is
- A pulsion pouch in the lowest 10 cm of the esophagus, just above the diaphragm.
- Cause
- Raised pressure from a motility disorder (achalasia, spasm, hypercontractile esophagus) in most cases.
- Symptoms
- Often none; dysphagia, regurgitation, chest pain, night cough, bad breath.
- Diagnosis
- Barium swallow, endoscopy, high-resolution manometry.
- Treatment
- Observation if no symptoms; surgery (myotomy with or without removing the pouch) or endoscopic procedures for symptoms.
When to get help
Call 911 or go to the ER
- Sudden severe chest pain after vomiting or a procedure, with fever or difficulty breathing (possible rupture). Call 911 or your local emergency number
- Vomiting blood
See a doctor within a day or two
- Coughing or choking at night with fever or chest symptoms (possible aspiration pneumonia)
- Food stuck with inability to swallow liquids
Book a routine appointment
- Difficulty swallowing, regurgitation of old food, or chest pressure after eating
- Unintended weight loss
- A pouch found on a scan, to discuss whether it needs follow-up
What an epiphrenic diverticulum is
A diverticulum is an outpouching of the wall of a hollow organ. Esophageal diverticula are classified by location:
| Type | Location | Mechanism |
|---|---|---|
| Zenker's diverticulum | Top of the esophagus, in the throat | Pulsion from a tight upper sphincter |
| Mid-esophageal diverticulum | Middle esophagus | Traction from scarred lymph nodes (often TB or histoplasmosis), or pulsion |
| Epiphrenic diverticulum | Lowest 10 cm, above the diaphragm | Pulsion from a motility disorder |
An epiphrenic diverticulum is a pulsion (false) diverticulum: the inner lining pushes out through the muscle layer because of high pressure. It usually bulges to the right side and can range from a few centimeters to very large.
Causes
Most patients have an underlying esophageal motility disorder:
- Achalasia: the lower esophageal sphincter fails to relax, so food meets resistance
- Esophageal spasm and hypercontractile ("jackhammer") esophagus
- Ineffective motility or other non-specific patterns
Less often it is associated with a hiatal hernia, a narrowing or prior surgery. It mostly affects middle-aged and older adults.
Symptoms
Many people have no symptoms. When present, symptoms often reflect both the motility disorder and the pouch:
- difficulty swallowing (dysphagia)
- regurgitation of undigested food, sometimes hours after eating
- chest pain or pressure
- heartburn
- coughing, especially when lying down at night
- bad breath
- weight loss
- recurrent chest infections from aspiration
Diagnosis
- Barium swallow (esophagram): the best test to show the pouch, its size and neck, and signs of achalasia.
- Upper endoscopy: examines the lining, excludes cancer (rarely found in long-standing pouches), and checks the lower sphincter.
- High-resolution esophageal manometry: identifies the underlying motility disorder, which guides treatment.
- CT scan: for large pouches or surgical planning.
Treatment
No symptoms
Small, asymptomatic pouches are usually monitored. Treatment of the underlying motility problem may be considered if symptoms develop.
Symptomatic diverticula
The key principle is to treat the cause, because removing the pouch alone often leads to leaks or recurrence.
- Surgical myotomy: cutting the tight muscle of the lower esophagus (Heller myotomy), usually combined with a partial fundoplication to limit reflux.
- Diverticulectomy: removal of the pouch with a stapler, often combined with myotomy, for large or very symptomatic pouches. Usually done laparoscopically or thoracoscopically.
- Endoscopic options: peroral endoscopic myotomy (POEM) and diverticular POEM (D-POEM), which divide the muscle and the wall between the pouch and esophagus from inside, are increasingly used in experienced centers.
- Pneumatic dilation or Botox for achalasia in people unfit for surgery.
Diet and positioning
Eating slowly, chewing well, upright posture after meals and raising the head of the bed reduce regurgitation and aspiration.
Complications
- aspiration pneumonia
- food retention and weight loss
- bleeding or ulceration in the pouch
- perforation, rarely
- cancer within the pouch, very rarely
- surgical complications such as leaks
Frequently asked questions
What is an epiphrenic diverticulum?
It is a pouch that bulges from the lower esophagus just above the diaphragm. It usually forms because of high pressure in the esophagus from a motility disorder such as achalasia or spasm. Many are found by chance and cause no symptoms.
What are the symptoms of an epiphrenic diverticulum?
Symptoms can include difficulty swallowing, regurgitation of undigested food, chest pain, heartburn, night-time coughing and bad breath. Large pouches can trap food and lead to aspiration. Many people have no symptoms at all.
Does an epiphrenic diverticulum need surgery?
Only if it causes symptoms. Surgery usually includes cutting the tight lower esophageal muscle (myotomy) to treat the underlying cause, sometimes with removal of the pouch. Endoscopic procedures are an option in experienced centers.
Can an esophageal diverticulum become cancer?
Cancer arising in an esophageal diverticulum is very rare. Endoscopy is used during evaluation to examine the lining, and new or worsening symptoms such as weight loss or bleeding should be reported.
Sources
This guide was written from current patient and clinical guidance, including:
- American Society for Gastrointestinal Endoscopy: Esophageal diverticula
- Society of American Gastrointestinal and Endoscopic Surgeons (SAGES): Esophageal diverticulum
- American College of Gastroenterology: Clinical guidelines on achalasia
- NIH National Library of Medicine (StatPearls): Esophageal diverticulum
- Merck Manual Professional Version: Esophageal diverticula