Epiphrenic diverticulum

Changed by Duncan Lyons, 14 Mar 2019

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Epiphrenic diverticula are pulsion diverticula of the distal oesophagus arising just above the lower oesophageal sphincter, more frequently on the right posterolateral wall.

They are less frequent than traction mid oesophageal diverticula but may have more clinical relevance.

Clinical presentation

Epiphrenic diverticula may present with symptoms of dysphagia, and regurgitation. When large they can cause distal oesophageal compression.

Pathology

These are considered to be pulsion type diverticula, thought to arise due to increased intraluminal pressure and hence the strong association with oesophageal dysmotility.

The diverticulum forms as the submucosa and mucosa herniate focally through the muscularis propria. Since the diverticular wall lacks the muscular layer, it is classified as a "false" diverticulum.

Associations

They are associated with:

achalasia and other forms of neuromuscular dysfunction of the oesophagus
hiatus hernia
oesophageal stricture
oesophageal web

Radiographic features

Plain radiograph

On chest x-ray, they may appear as a retrocardiac soft tissue mass with or without an air-fluid level, mimicking a hiatus hernia.

Fluoroscopy

The best imaging method is a single contrast oesophagogram, including prone RAO oblique views of the distal oesophagus.

determine the relationship between the diverticulum and the gastro-oesophageal junction
look for evidence of oesophageal motility disorders and hiatus hernia

Treatment and prognosis

~~Epiphrenic~~

Conservative treatment can still be trialled for the treatment of an epiphrenic diverticulum ⁴. If incidentally found or in patients experiencing mild symptoms, conservative treatment and a period of observation can lead to complete resolution of symptoms. If symptoms persist, or in severely symptomatic patients with a large diverticulum, then surgical intervention is required ⁵. Surgical options include for epiphrenic diverticula ~~can be treated surgically with~~include myomectomy or diverticulectomy.

Differential diagnosis

distal oesophageal "ballooning" after an oesophageal myotomy
hiatal hernia

~~-<li>determine the relationship between the diverticulum and the <a title="Gastro-oesophageal junction" href="/articles/gastro-oesophageal-junction">gastro-oesophageal junction</a>~~
+<li>determine the relationship between the diverticulum and the <a href="/articles/gastro-oesophageal-junction">gastro-oesophageal junction</a>
~~-</ul><h4>Treatment and prognosis</h4><p>Epiphrenic diverticula can be treated surgically with myomectomy or diverticulectomy.</p><h4>Differential diagnosis</h4><ul>~~
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+<![endif]--></p><p>Conservative treatment can still be trialled for the treatment of an epiphrenic diverticulum <sup>4</sup>. If incidentally found or in patients experiencing mild symptoms, conservative treatment and a period of observation can lead to complete resolution of symptoms. If symptoms persist, or in severely symptomatic patients with a large diverticulum, then surgical intervention is required <sup>5</sup>. Surgical options include for epiphrenic diverticula include myomectomy or diverticulectomy.</p><h4>Differential diagnosis</h4><ul>

References changed:

4. Tedesco P, Fisichella PM, Way LW, Patti MG. Cause and treatment of epiphrenic diverticula. (2005) American journal of surgery. 190 (6): 891-4. <a href="https://doi.org/10.1016/j.amjsurg.2005.08.016">doi:10.1016/j.amjsurg.2005.08.016</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/16307941">Pubmed</a> <span class="ref_v4"></span>
5. Castucucci G, Porziella V, Granone PL, Picciocchi A. Tailored surgery for esophageal body diverticula. Eur J Cardiothorac Surg. 1998; 14:380-7. <a href="http://www.ncbi.nlm.nih.gov/pubmed/?term=%20%20:9845142</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/?term=%20%20:9845142">Pubmed</a> <span class="ref_v4"></span>

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