El Salvador Atlas of Gastrointestinal VideoEndoscopy. A Large Database of Images and Video Clips with Cases Reported.
El Salvador Atlas of Gastrointestinal VideoEndoscopy
Zenker's Diverticulum. This 75 year-old male presented with of increasing dysphagia with nocturnal regurgitation of partially digested food material. Zenker diverticulum is rare, occurs in elderly populations, and results in a classic presentation of symptoms. The condition has severe complications, including aspiration and pneumonia, and is managed by surgical repair. or with endoscopic management. Pharyngoesophageal diverticulum, also known as Zenker?s diverticulum (ZD), is an acquired disease that is formed by the outpouching of hypopharyngeal mucosa between the inferior pharyngeal constrictor muscle and the cricopharyngeal muscle in an area of junctional muscle weakness known as Killian?s triangle. Its pathophysiology is not well known.

Video Endoscopic Sequence 1 of 8.

Endoscopy of Zenker's Diverticulum

 This 75 year-old male presented with of increasing
 dysphagia with nocturnal regurgitation of partially digested
 food material.

 Zenker diverticulum is rare, occurs in elderly populations,
 and results in a classic presentation of symptoms. The
 condition has severe complications, including aspiration
 and pneumonia, and is managed by surgical repair. or with
 endoscopic management.

 Pharyngoesophageal diverticulum, also known as Zenker’s
 diverticulum (ZD), is an acquired disease that is formed by
 the outpouching of hypopharyngeal mucosa between the
 inferior pharyngeal constrictor muscle and the
 cricopharyngeal muscle in an area of junctional muscle
 weakness known as Killian’s triangle. Its pathophysiology
 is not well known.

 

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 endoscopic images shown in this Atlas contain video clips.
 We recommend seeing the video clips in full screen mode.

 
In 1877, Friedrich Albert von Zenker, professor of pathology at Erlangen University in Germany, described the pulsion diverticulum that bears his name. His series included 5 personal cases and 22 cases collected from the literature. In the beginning of the 20th century, Killian identified the origin of the diverticulum between the cricopharyngeus muscle and the inferior pharyngeal constrictor muscles. Wheeler first successfully resected this pharyngoesophageal diverticulum in 1886.

Video Endoscopic Sequence 2 of 8.

It has some old food trapped in it

 In 1877, Friedrich Albert von Zenker, professor of
 pathology at Erlangen University in Germany, described
 the pulsion diverticulum that bears his name. His series
 included 5 personal cases and 22 cases collected from the
 literature. In the beginning of the 20th century, Killian
 identified the origin of the diverticulum between the
 cricopharyngeus muscle and the inferior pharyngeal
 constrictor muscles. Wheeler first successfully resected
 this pharyngoesophageal diverticulum in 1886.
Retroflexed image showing the Nasopharynx. Canalization of the esophagus with Zenker diverticulum is not an easy task, in our patient some, several attempts to bring forward the esophagus was performed, until we succeed in passing an thin endoscope. Patients present with upper esophageal dysphagia, regurgitation of undigested food, aspiration, noisy deglutition, halitosis, and changes in voice. Mild-to-moderate weight loss is frequent. Aspiration and pneumonia are potentially serious complications. Although the diverticulum can reach sizes of 15 cm or more, it is rarely palpable. Squamous cell carcinoma has been found in the diverticulum in less than 0.5% of specimens. Coexistent hiatal hernia, esophageal spasm, achalasia, and esophagogastroduodenal ulceration are common.

Video Endoscopic Sequence 3 of 8.

Retroflexed image showing the Nasopharynx.

 Canalization of the esophagus with Zenker diverticulum is
 not an easy task, in our patient some, several attempts to
 bring forward the esophagus was performed, until we
 succeed in passing an thin endoscope.

 Patients present with upper esophageal dysphagia,
 regurgitation of undigested food, aspiration, noisy
 deglutition, halitosis, and changes in voice.
 Mild-to-moderate weight loss is frequent. Aspiration and
 pneumonia are potentially serious complications. Although
 the diverticulum can reach sizes of 15 cm or more, it is
 rarely palpable. Squamous cell carcinoma has been found
 in the diverticulum in less than 0.5% of specimens.
 Coexistent hiatal hernia, esophageal spasm, achalasia, and
 esophagogastroduodenal ulceration are common.
The septum between the diverticula and the upper sphincter. The endoscopic treatment of symptomatic pharyngoesophageal diverticula involves the incision of the septum between the diverticulum and the esophageal lumen, within which the cricopharyngeal muscle is present. Zenker?s diverticulum (ZD) is an uncommon disease, which is typically treated surgically. The alternative to surgery is a diverticulotomy, performed endoscopically. The endoscopic treatment of ZD can achieve the same clinical results as surgical treatment while reducing the incidence of complications and mortality. The endoscopic treatment of symptomatic pharyngoesophageal diverticula involves the incision of the septum between the diverticulum and the esophageal lumen, within which the cricopharyngeal muscle is present. Zenker?s diverticulum (ZD) is an uncommon disease, which is typically treated surgically. The alternative to surgery is a diverticulotomy, performed endoscopically. The endoscopic treatment of ZD can achieve the same clinical results as surgical treatment while reducing the incidence of complications and mortality.

Video Endoscopic Sequence 4 of 8.

The septum between the diverticula and the upper sphincter

Endoscopic view of the common wall between the cervical esophagus and the diverticula.

 The endoscopic treatment of symptomatic
 pharyngoesophageal diverticula involves the incision of
 the septum between the diverticulum and the esophageal
 lumen, within which the cricopharyngeal muscle is present.
 Zenker’s diverticulum (ZD) is an uncommon disease, which
 is typically treated surgically. The alternative to surgery is
 a diverticulotomy, performed endoscopically. The
 endoscopic treatment of ZD can achieve the same clinical
 results as surgical treatment while reducing the incidence
 of complications and mortality.

 The endoscopic intraluminal treatment of ZD by use of a
 flexible endoscope is nowadays an alternative to surgical
 treatment. A monopolar forceps or a needle-knife is used
 to cut the ZD bridge. Argon plasma coagulation (APC) has
 also been used for this purpose. In order to have a better
 view during the procedure, devices were developed such as
 a hood attached to the endoscope and a flexible overtube
 called a diverticuloscope.

 
To overcome the pressure exerted by the diverticulum in the upper esophageal sphincter, we used an pediatric endoscope to perform the endoscopy with some difficulty the scope is passed into the esophagus, and then slowly withdrawn.

Video Endoscopic Sequence 5 of 8.

 To overcome the pressure exerted by the diverticulum in
 the upper esophageal sphincter, we used a pediatric
 endoscope to perform the endoscopy with some difficulty
 the scope is passed into the esophagus, and then slowly
 withdrawn.
The fluoroscopic barium esophagram is the primary tool for the diagnosis of Zenker diverticulum. The diverticulum appears as an outpouching arising from the midline of the posterior wall of the distal pharynx near the pharyngoesophageal junction. This is best identified during swallowing and is best seen on the lateral view, on which the diverticulum is typically noted at the C5-6 level.

Video Endoscopic Sequence 6 of 8.

 The fluoroscopic barium esophagram is the primary tool
 for the diagnosis of Zenker diverticulum. The diverticulum
 appears as an outpouching arising from the midline of the
 posterior wall of the distal pharynx near the
 pharyngoesophageal junction. This is best identified during
 swallowing and is best seen on the lateral view, on which
 the diverticulum is typically noted at the C5-6 level.

 
Frequently, a posterior bar representing a prominent cricopharyngeus muscle is noted as the contrast bolus passes. As the contrast bolus normally travels quickly through the pharynx and upper esophagus, careful observation during fluoroscopy is necessary, and videofluoroscopy is helpful for documentation purposes.

Video Endoscopic Sequence 7 of 8.

 Frequently, a posterior bar representing a prominent
 cricopharyngeus muscle is noted as the contrast bolus
 passes. As the contrast bolus normally travels quickly
 through the pharynx and upper esophagus, careful
 observation during fluoroscopy is necessary, and
 videofluoroscopy is helpful for documentation purposes.

 
When the diverticulum is large enough to protrude laterally, it protrudes to the left in 90% of the cases. After the contrast agent bolus passes the upper esophagus, the diverticulum is typically seen extending posterior to the cricopharyngeus muscle, and contrast material that was trapped within the diverticulum may be regurgitated back into the hypopharynx. A Valsalva maneuver may be helpful in visualizing the diverticulum after swallowing. Occasionally, a patient may aspirate contrast material from the diverticulum. Pay attention to the lumen of the diverticulum because irregularities or filling defects within the diverticulum may indicate the rare complication of squamous cell carcinoma.

Video Endoscopic Sequence 8 of 8.

 When the diverticulum is large enough to protrude
 laterally, it protrudes to the left in 90% of the cases. After
 the contrast agent bolus passes the upper esophagus, the
 diverticulum is typically seen extending posterior to the
 cricopharyngeus muscle, and contrast material that was
 trapped within the diverticulum may be regurgitated back
 into the hypopharynx.

 A Valsalva maneuver may be helpful in visualizing the
 diverticulum after swallowing. Occasionally, a patient may
 aspirate contrast material from the diverticulum. Pay
 attention to the lumen of the diverticulum because
 irregularities or filling defects within the diverticulum may
 indicate the rare complication of squamous cell carcinoma.
Mid Esophageal Diverticulum. Almost all esophageal diverticula are acquired pulsion diverticula. The most common symptoms are dysphagia, regurgitation, thoracic pain, and pulmonary manifestations related to aspiration.

Video Endoscopic Sequence 1 of 3.

Mid Esophageal Diverticulum.

 Almost all esophageal diverticula are acquired pulsion
 diverticula. The most common symptoms are dysphagia,
 regurgitation, thoracic pain, and pulmonary manifestations
 related to aspiration.

 
Midesophageal diverticulum. The exact cause of a mid-esophageal diverticulum is not known but the condition has been associated with scarring and various esophageal motor abnormalities.

Video Endoscopic Sequence 2 of 3.

Midesophageal Diverticulum.

 The exact cause of a mid-esophageal diverticulum is not
 known but the condition has been associated with scarring
 and various esophageal motor abnormalities.

 

 
Esophageal Inlet Patch. Salmon-colored patch of mucosa found in the proximal esophagus, just below the upper esophageal sphincter. This represents an island of heterotopic gastric mucosa. Heterotopic gastric mucosa may occur throughout the gastrointestinal tract, including the upper esophagus. The capability of this ectopic mucosa to secrete acid has been suggested in different reports.

Video Endoscopic Sequence 3 of 3.

Esophageal Inlet Patch.

 Besides the esophageal diverticulum, the patient has
 an island of heterotopic gastric mucosa in the upper third.

 Salmon-colored patch of mucosa found in the proximal
 esophagus, just below the upper esophageal sphincter.
 This represents an island of heterotopic gastric mucosa.
 
 Heterotopic gastric mucosa may occur throughout the
 gastrointestinal tract, including the upper esophagus. The
 capability of this ectopic mucosa to secrete acid has been
 suggested in different reports.


                                          Medline.
This 69 year old male, has been complained of dysphagia with nocturnal regurgitation of partially digested food material. Endoscopy shows the diverticula and the septum.

Zenker's Diverticulum

This 69 year old male, has been complained of dysphagia with nocturnal regurgitation of partially digested
 food material.

Endoscopy shows the diverticula and the septum

 Pharyngeal diverticulae may be posterior, posterolateral,
 or lateral (pharyngocoele) but the most commonly
 encountered type is the posterior pulsion diverticulum.
 There is usually a single opening at Killian's dehiscence,
 although the presence of a double pharyngeal pouch has
 been reported.the majority of pharyngeal pouches protrude
 to the left side and it has been suggested that the
 handedness of the patient may determine the side on which
 the pouch occurs.
Zenkerīs Diverticula.

Zenkerīs Diverticula

The radiologic study shows the pharyngoesophageal (Zenker’s) diverticulum.

 Esophageal diverticula are more or less pronounced
 saccular protrusions of the esophageal wall. Traction
 diverticula (e.g., caused by extrinsic traction) affect the
 entire wall thickness, while in pulsion diverticula only the
 mucosa and submucosa protrude through a gap in the
 muscular wall. There are three sites of predilection for
 diverticula in the esophagus: cervical diverticula
 (synonym: Zenker diverticula, comprising approximately
 70% of all esophageal diverticula), thoracic diverticula
 (approximately 22%), and epiphrenic diverticula
 (approximately 8%).
Esophageal Mucosal Bridge. An 80 year-old female with esophageal mucosal bridge and esophageal diverticula, was found as an incidental finding on a routine endoscopy, two years previously we did not find this image only the diverticula of the middle third.

Video Endoscopic Sequence 1 of 3

 Esophageal Mucosal Bridge.

 An 80 year-old female with esophageal mucosal bridge and
 esophageal diverticula, was found as an incidental finding
 on a routine endoscopy, two years previously we did not
 find this image only the diverticula of the middle third.

 The mucosal bridge is oriented in the long axis of the
 esophagus.

 Mucosal bridges are classified into congenital and
 secondary types. Congenital mucosal bridges are rare

 Secondary mucosal bridges have been associated with
 reflux esophagitis, Barrett’s mucosa sclerotherapy,
 hematoma, malignant tumors, corrosive esophagitis,
 drug-induced esophagitis, radiation esophagitis,
 submucosal dissection (hematoma), systemic lupus
 erythematosus (SLE), dermatomyositis with esophageal
 ulcer, Mallory–Weiss syndrome, and candidiasis.

Esophageal Mucosal Bridge. Longitudinal Esophageal Mucosal Bridge and a diverticula.

Video Endoscopic Sequence 2 of 3.

Longitudinal Esophageal Mucosal Bridge and a diverticula.

 Mucosal bridges may extend obliquely or horizontally
 across the esophageal lumen. first such case was reported
 in 1969 by Dafoe and Ross. More recently, incidental
 mucosal bridges have often been demonstrated at
 endoscopy, but only a few patients with symptoms
 attributable to this disorder have been reported.
 bridges usually occur in the mid- and lower esophagus.

 
Esophageal diverticulum. This is the image of the middle third of the esophagus found it two years previously, esophageal mucosal bridge was not found at that time. The esophageal lumen is slightly displaced by the distal margin of the diverticulum.

Video Endoscopic Sequence 3 of 3.

Esophageal Diverticulum.

 This is the image of the middle third of the esophagus
 found it two years previously, esophageal mucosal bridge
 was not found at that time.
 The esophageal lumen is slightly displaced by the distal
 margin of the diverticulum.