Esophageal Diverticula

Esophageal Diverticula

DRG Category:394
Mean LOS:4.4 days
Description:MEDICAL: Other Digestive System Diagnoses With CC
DRG Category:326
Mean LOS:15.4 days
Description:SURGICAL: Stomach, Esophageal, and Duodenal Procedure With Major CC

Esophageal diverticula, or herniations of the esophageal mucosa, are hollow outpouchings of the esophageal wall that occur in three main areas of the esophagus: proximally near the anatomic hypopharyngeal sphincter (Zenker’s diverticulum, the most common location), near the midpoint of the esophagus (a midesophageal diverticulum), and just above the lower esophageal sphincter (an epiphrenic diverticulum, the least common location). Food, fluids, and secretions accumulate in these dilated outpouchings, creating discomfort. Aspiration pneumonia, bronchitis, bronchiectasis, and lung abscess may be the result of regurgitating contents of the esophageal diverticula. Esophageal diverticula may also lead to esophageal perforation.

Causes

Esophageal diverticula develop from weakened esophageal musculature (congenital and acquired), traumatic injury, and scar tissue associated with chronic inflammation. Developmental muscle weakness of the posterior pharynx above the border of the cricopharyngeal muscle leads to Zenker’s diverticulum. Pressure caused by swallowing and contraction of the pharynx before the sphincter relaxes aggravates the muscle weakness and results in the development of diverticula. A response to scarring and pulling on esophageal walls by an external inflammatory process, such as tuberculosis, or by traction from old adhesions may lead to midesophageal diverticula. Other causes of esophageal diverticula include motor disturbances, such as achalasia (absence of normal peristalsis in esophageal smooth muscle and elevated pressure at the physiological cardiac sphincter), diffuse esophageal spasms, and reflux esophagitis.

Genetic considerations

Esophageal diverticula do appear to run in families. They are also a feature of autosomal dominantly inherited polycystic kidney disease.

Gender, ethnic/racial, and life span considerations

Infants and children have been known to have esophageal diverticula, although the disorder predominantly occurs in adults beyond midlife after they reach age 50. It affects men three times as often as women. Epiphrenic diverticula usually occur in middle-aged men. Zenker’s diverticulum occurs most often in men over age 60. There are no known racial or ethnic considerations.

Global health considerations

No data are available.

Assessment

History

Establish a recent history of weight loss, which is generally attributed to difficulty in eating. Determine if the patient has experienced subtle, gradually progressive esophageal dysphagia that primarily affected the swallowing of solid foods. Achalasia (“failure to relax”; refers to inability of the lower esophageal sphincter to open so that food may pass into the stomach) can lead to dysphagia. Ask if the patient has experienced gagging, gurgling, or a sense of fullness in the throat as if something were “stuck.” Inquire whether the patient has regurgitated food particles and saliva soon after eating. Determine if the patient has experienced an unpleasant taste and nocturnal coughing with regurgitation of retained secretions and undigested foods. Establish a history of heartburn following ingestion of coffee, alcohol, chocolate, citrus juices, or fatty foods, particularly when the patient was bending over or lying down within 2 hours of intake. These indicators suggest that the esophageal diverticula are secondary to achalasia.

Physical examination

The most common symptoms are dysphagia, achalasia, weight loss, and regurgitation. Assess the patient’s appearance, noting apparent weight loss or the malnourished look that is associated with anorexia. Note halitosis, a common sign of esophageal diverticula. Inspect the patient’s neck for visible signs of esophageal distention that has been caused by food trapped in the diverticula.

Psychosocial

The patient may experience self-imposed social isolation because of feelings of embarrassment that are caused by noisy swallowing, unusual facial expressions during eating, or halitosis. The patient may become depressed because of the loss of pleasure and socialization connected with eating, along with grieving over the loss of dietary preferences. The patient’s family may be anxious about the social effects of the patient’s disease as well.

Diagnostic highlights

TestNormal ResultAbnormality With ConditionExplanation
Esophageal manometryMultilumen esophageal catheter is introduced through the mouth, and pressures along the esophagus are measured during swallowing: normal contractions, swallowing, peristalsisAbnormal contractions, swallowing, and peristalsisAssesses and diagnoses dysphagia, esophageal reflux, spasm, motility abnormalities, hiatal hernia
Barium swallowNormal esophagusIdentifies irregular or abnormal areas of the esophagusLocates and describes irregularities in the esophageal wall
EsophagoscopyVisualization of a normal esophagusDirect visualization of diverticulaLocates esophageal diverticula

Primary nursing diagnosis

Diagnosis

Risk for aspiration related to regurgitation of food, fluid, or secretions that have accumulated in diverticula

Outcomes

Knowledge: Treatment procedures; Respiratory status: Ventilation; Neurological status; Nutritional status: Food and fluid intake; Oral health; Self-care: Eating

Interventions

Airway suctioning; Surveillance; Respiratory monitoring; Feeding; Positioning

Planning and implementation

Collaborative

medical.
When achalasia is implicated, pharmacologic therapy may be chosen as the first option. It can also be treated with pneumatic dilation or botulinum toxin injection (onabotulinumtoxinA, or Botox) into the lower esophageal sphincter during endoscopy. Assess the effects of treatments because the drugs may worsen the diverticula by relaxing an already weakened esophageal musculature.

surgical.
An esophagomyotomy (incision into the esophageal musculature) and diverticulectomy (surgical removal of the diverticulum) may be warranted, particularly for patients with Zenker’s diverticulum. A cricopharyngeal myotomy, a procedure in which the surgeon divides the cricopharyngeal muscle, involves cutting the muscle to make it incompetent so that when the individual swallows, the muscle relaxes and allows food to pass through. Postoperative care is determined by the incisional approach. With a cervical approach, a drain is commonly inserted in the neck to diminish edema at the incisional site. A chest incision (thoracic approach) requires care associated with a thoracotomy. Postoperative care is directed at monitoring the patency of the airway, maintaining pulmonary ventilation by chest drainage with chest tubes, monitoring neck drainage with either gravity drainage or low suction, and preventing aspiration.

Pharmacologic highlights

Medication or Drug ClassDosageDescriptionRationale
Smooth muscle relaxantsVaries with drugNitrates or calcium channel blockersRelax the cardiac sphincter, preventing reflux of foods
OnabotulinumtoxinA (Botox)80 to 100 units, 20 to 25 units in each of four quadrantsNeuromuscular blocking agentInhibits acetylcholine, relaxes smooth muscles, and reduces lower esophageal sphincter resting pressure
AntacidsVaries with drugAmphojel, AlternaGEL, Gelusil, Maalox, MylantaNeutralize gastric acid and reduce symptoms, especially with midesophageal or epiphrenic diverticula, because they usually do not produce complications

Other Drugs: Botulinum toxin A (Botox); interferes with cholinergic transmission of the myenteric plexus and leads to smooth muscle relaxation

Independent

Care focuses on maintaining a patent airway, preventing aspiration of regurgitated food and mucus, providing emotional support, and providing adequate nutrition. Implement interventions to maintain airway patency if there is any suspicion it is at risk. Use the jaw thrust or chin lift or insert an oral or nasal airway. Prevent aspiration of regurgitated food and mucus by positioning the patient carefully, with her or his head elevated or turned to one side. Recommend that the patient sleep with the head elevated (using pillows or bed blocks) to reduce esophageal reflux and nocturnal choking. Show the patient how to use massage to empty any visible outpouching to the neck to prevent aspiration during sleep.

Education, rather than medical or surgical intervention, may become the treatment of choice. Provide the patient with information on lifestyle changes to reduce symptoms. Teach appropriate nutrition. Advise the patient to explore textures and quantities of foods to determine which cause the least discomfort. Recommend that the patient consider semisoft and soft foods and advise adding fiber to the diet to stimulate peristalsis of the gastrointestinal (GI) system, reducing lower GI tract pressure on the esophagus. Recommend food supplements between meals to prevent weight loss and malnourishment and advise the patient to drink fluids intermittently with meals to aid in propulsion of the food bolus through the esophagus. Teach the patient to concentrate on the act of eating to maximize each phase of the process of ingesting food and fluids, moistening the mouth before eating to facilitate chewing and swallowing. Explain how to use Valsalva’s maneuver to increase esophageal pressure, thus facilitating food bolus movement beyond the hypopharyngeal sphincter. Recommend that the patient sit upright when eating or drinking to facilitate gravitational flow through the esophagus, and advise remaining upright for at least 2 hours after eating.

Advise taking adequate fluids (> 15 mL) with medications to prevent chemical esophageal irritation. Recommend eliminating oral drugs immediately before bedtime to decrease the risk of deposits in diverticula that can create ulceration. Advise the patient to avoid food or fluids within 3 to 4 hours of bedtime to reduce nocturnal symptoms.

Evidence-Based Practice and Health Policy

Hirano, Y., Takeuchi, H., Oyama, T., Saikawa, Y., Niihara, M., Sako, H., …Kitagawa, Y. (2013). Minimally invasive surgery for esophageal epiphrenic diverticulum: The results of 133 patients in 25 published series and our experience. Surgery Today, 43(1), 1–7.

  • In a systematic review of 25 articles in which 133 patients with esophageal diverticula were identified, mortality occurred in 2% of the patients and morbidity occurred in 21%. Causes of morbidity were related to staple-line leak (15%), dysphagia (3%), pneumonitis (2%), gastroesophageal reflux disease (2%), and diverticulum recurrence (1%).
  • Motility disorders were also identified in 68% of patients, including achalasia (29%), diffuse esophageal spasm (30%), and hypertensive lower esophageal sphincter (9%).

Documentation guidelines

  • Physical findings: Rate and depth of respirations; breath sounds; presence of dysphagia, choking, or regurgitation
  • Changes (improvement or lack of improvement) of symptoms
  • Halitosis, dysphagia, regurgitation, gurgling with swallowing, coughing, persistence of a bad taste in the mouth
  • Complications: Airway swelling, fever, productive cough, respiratory distress, weight loss, poor wound healing, wound infection

Discharge and home healthcare guidelines

patient teaching.
Teach the patient methods to reduce symptoms, prevent malnutrition and weight loss, and improve sleep and rest. Make sure the patient understands the dosage, route, action and purpose, side effects, and contraindications of the prescribed medications. Explain the potential for aspiration, respiratory impairment, weight loss or malnourishment, and sleep deprivation. Remind the patient to see the physician if symptoms of esophageal diverticula return or worsen.

References in periodicals archive ?
Modern patho-physiology and treatment of esophageal diverticula.
Medication decisions in giant Zenker's and esophageal diverticula.
5% had anatomical obstacles, such as large hiatal hernias, esophageal diverticula, or prior nasal surgery.