Mid-Esophageal Diverticulum

Where esophageal diverticula occur

Mid-esophageal diverticula are the least common of the three.

Causes

Traction diverticulum

Lymph nodes beside the esophagus in the middle of the chest can become inflamed from infections such as tuberculosis or histoplasmosis, or from sarcoidosis. As they heal and scar, they pull on the esophageal wall and tent it outward. Traction diverticula contain all layers of the esophageal wall (true diverticula), are often small with a wide neck, and drain well, so they rarely cause symptoms.

Pulsion diverticulum

Esophageal motility disorders, such as achalasia, diffuse esophageal spasm and hypercontractile esophagus, raise pressure inside the esophagus. Over time, the lining pushes out through a weak spot in the muscle, forming a pouch. These are often larger and more likely to cause symptoms. Many mid-esophageal diverticula once thought to be traction type are now recognized as pulsion type linked to motility problems.

Symptoms

Many people have no symptoms. When symptoms occur, they include:

• difficulty swallowing (dysphagia), often a feeling of food sticking in the chest
• regurgitation of undigested food, sometimes hours after eating
• chest pain or heartburn
• bad breath
• cough, especially when lying down, from food spilling back up
• weight loss in severe cases

Complications

Complications are uncommon but can be serious:

• aspiration of pouch contents into the lungs, causing pneumonia
• fistula, an abnormal connection between the diverticulum and the airway, causing coughing with every swallow
• bleeding from ulceration
• perforation, especially during endoscopy or tube placement
• cancer arising in the pouch, rare

Diagnosis

• Barium swallow (esophagram): X-ray images while swallowing contrast show the pouch, its size and neck
• Upper endoscopy: looks at the lining, rules out cancer, and must be done carefully to avoid entering the pouch
• High-resolution esophageal manometry: measures muscle contractions to detect an underlying motility disorder, important before surgery
• CT scan of the chest: shows calcified lymph nodes and the relationship to nearby structures, and detects fistulas

Treatment

No symptoms

Small, asymptomatic diverticula, especially traction type, usually need no treatment. Some doctors repeat imaging if the pouch is large.

Symptomatic diverticula

• Treat the motility disorder: this is essential, because removing the pouch without addressing high pressure can lead to recurrence or leaks.
• Surgery: diverticulectomy (removing the pouch) with a myotomy (cutting the tight muscle) when a motility disorder is present. Performed through minimally invasive chest surgery (thoracoscopy) or open surgery.
• Endoscopic options: peroral endoscopic myotomy (POEM) or diverticular POEM in selected cases at specialized centers.
• Fistula repair if a connection to the airway is present.

Diet and lifestyle

For mild symptoms:

• eat slowly, chew thoroughly, and take smaller bites
• drink water with meals
• stay upright for 30 to 60 minutes after eating
• raise the head of the bed if regurgitation occurs at night

Outlook

Most mid-esophageal diverticula cause no problems and do not need treatment. Surgery for symptomatic cases usually relieves swallowing problems, but it is complex and best done in experienced centers.

Frequently asked questions

What is a mid-esophageal diverticulum?

It is a pouch that bulges out from the middle portion of the esophagus in the chest. It is usually caused by scarring from nearby inflamed lymph nodes or by high pressure from an esophageal muscle disorder.

What are the symptoms of an esophageal diverticulum?

Many people have no symptoms. Others notice difficulty swallowing, food sticking in the chest, regurgitation of undigested food, chest pain, bad breath or coughing, especially at night or when lying down.

What causes a traction diverticulum?

A traction diverticulum forms when inflamed lymph nodes beside the esophagus, often from old tuberculosis or histoplasmosis, scar and pull the esophageal wall outward. These diverticula are usually small and cause few symptoms.

Does an esophageal diverticulum need surgery?

Only if it causes significant symptoms or complications. Surgery removes the pouch and treats any underlying muscle disorder. Small pouches without symptoms are usually left alone.

Can an esophageal diverticulum become cancer?

Rarely. Long-standing irritation from trapped food can, in rare cases, lead to cancer in the pouch. New or worsening symptoms, bleeding or weight loss should be investigated with endoscopy.