A 68-year-old woman comes to the office due to food getting "stuck" in her throat, which has worsened over the past 2 years. She occasionally has to get out of bed to vomit, although she does not vomit during the day. She has not changed her diet or lost weight. Medical history includes obesity, hypertension, and diabetes. A barium esophagogram is shown in the image below. Which of the following is the most appropriate next step in management of this patient?

Question

A 68-year-old woman comes to the office due to food getting "stuck" in her throat, which has worsened over the past 2 years.  She occasionally has to get out of bed to vomit, although she does not vomit during the day.  She has not changed her diet or lost weight.  Medical history includes obesity, hypertension, and diabetes.  A barium esophagogram is shown in the image below.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d81f_7621_bc81_7d71cfbbd5d7_MD0003_00 This patient's lateral view of a contrast esophagogram shows a posterior outpouching of the cervical esophagus that is connected to the true lumen. This is consistent with a Zenker (pharyngoesophageal) diverticulum (ZD). The diverticular pouch can trap food and medication. Patients often regurgitate the undigested food or medications several hours after eating. This can be more pronounced when the individual lies supine, as in this patient. Zenker (pharyngoesophageal) diverticulum (ZD) Abnormal spasm or diminished relaxation of the cricopharyngeal muscles during swallowing (cricopharyngeal motor dysfunction) is thought to be the underlying mechanism of ZD formation. Increased intraluminal pressure above the cricopharyngeus muscle eventually results in herniation of the mucosa through an area of weakness. Therefore, ZD is classified as a pulsion (resulting from increased intraluminal forces), rather than a traction (resulting from external tugging forces), pseudodiverticulum. pseudodiverticulum Treatment of symptomatic patients involves surgical division of the cricopharyngeus muscle (cricopharyngeal myotomy). The diverticular pouch can be removed or combined with the esophageal lumen. (Choice B) Esophageal balloon dilation is used to treat benign esophageal strictures, which present with dysphagia limited to solid foods. However, on swallow study, strictures appear as a smoothly tapering, concentric narrowing of the esophageal lumen. (Choice C) Ligamentum arteriosum ligation is used to treat some patients with vascular ring, a congenital malformation of the aortic arch system that encircles the trachea and/or esophagus and can cause compressive symptoms. A contrasted swallow study would show external compression of the esophagus rather than a diverticular pouch. vascular ring (Choices D and E) Oral metoclopramide may be used for gastroparesis to improve motility but is rarely used for esophageal disease. Oral omeprazole is used to treat gastroesophageal reflux disease, which often coexists with ZD. Medical therapy would not improve the underlying cricopharyngeal dysfunction or the diverticular pouch. (Choice F) Swallowing rehabilitation is used to treat patients with oropharyngeal dysphagia due to neurologic disease, trauma, or surgery. It typically strengthens oropharyngeal musculature but would not relax the cricopharyngeus muscle. Educational objective: Impaired relaxation of the cricopharyngeus muscle during swallowing may lead to the formation of a Zenker diverticulum, which is seen on contrast swallow study as a pouch posterior to the esophagus. Treatment is surgical with cricopharyngeal myotomy with or without diverticulectomy. References: Zenker's diverticulum: exploring treatment options. (http://www.ncbi.nlm.nih.gov/pubmed/24043908)

A 68-Year-Old Woman Comes to the Office Due to Food