Esophageal Diverticulum
An esophageal diverticulum is an outpouching of the esophageal wall that creates a small pouch where food, saliva, or fluid can collect. Diverticula can occur anywhere along the esophagus and are categorized by location—Zenker (upper), midesophageal, and epiphrenic (just above the diaphragm). Some are small and asymptomatic, while others can cause difficulty swallowing, regurgitation, bad breath, or aspiration. Imaging—particularly barium swallow studies and CT—and upper endoscopy are used to identify and characterize esophageal diverticula and guide treatment.
What is it?
A diverticulum is an outpouching that extends from a hollow organ. In the esophagus, a diverticulum forms when part of the esophageal wall bulges outward, creating a small pouch that can collect food, saliva, or fluid as it travels down the esophagus. Esophageal diverticula can vary widely in size, from small and incidental to large and clinically important.
Esophageal diverticula are usually classified by location. Zenker diverticulum is the most common type and arises just above the upper esophageal sphincter, in a weak area of the back of the throat-esophagus junction. It is most often seen in adults over age 60 and is related to abnormal pressure during swallowing. Midesophageal diverticula occur in the middle portion of the esophagus and can be associated with longstanding inflammation (such as from prior tuberculosis or other infections that affected nearby lymph nodes) or with motility disorders. Epiphrenic diverticula occur just above the diaphragm, near the lower esophageal sphincter, and are commonly associated with esophageal motility disorders such as achalasia.
Diverticula are also described by how they form. True diverticula involve all layers of the esophageal wall and tend to be related to traction from inflammation in nearby tissues, classically in the midesophagus. False diverticula (more common, including Zenker and epiphrenic) involve only the inner layers of the wall, which pouch outward through a weakness in the muscular layer, often driven by abnormal swallowing pressures or motility problems.
Many esophageal diverticula are small and cause no symptoms. When symptoms occur, they depend on the size and location of the pouch. Patients with Zenker diverticulum often describe difficulty swallowing, regurgitation of undigested food (sometimes hours after eating), a sensation of food sticking in the upper throat, gurgling sounds in the neck, bad breath, frequent throat clearing, and recurrent cough or aspiration. Midesophageal and epiphrenic diverticula may produce chest discomfort, difficulty swallowing, regurgitation, and, when associated with motility disorders, additional symptoms such as chest pain with swallowing or significant difficulty advancing food and liquid into the stomach. Recurrent aspiration—when material from a diverticulum spills into the airway—can lead to chronic cough, hoarseness, or pneumonia.
Barium swallow studies are often the most useful imaging test for identifying and characterizing esophageal diverticula because they show the size, location, and shape of the pouch in real time, along with how well the esophagus moves food and liquid. CT of the chest and upper abdomen can identify diverticula, evaluate their relationship to nearby structures, and look for complications. Upper endoscopy is important to inspect the inside of the esophagus and exclude other conditions, though care is taken when a diverticulum is suspected to avoid injury during the procedure. Esophageal manometry helps identify underlying motility disorders that may be driving the formation of certain diverticula.
Important to Know
Treatment of esophageal diverticula is individualized based on the location, size, symptoms, and any associated conditions such as motility disorders. Small, asymptomatic diverticula often require no specific treatment beyond reassurance and follow-up. Mild symptoms can sometimes be managed with dietary measures, eating slowly, sitting upright after meals, and other positional strategies.
For more symptomatic diverticula—particularly larger Zenker diverticula and symptomatic epiphrenic diverticula—procedural treatment is often considered. Zenker diverticulum is commonly treated with endoscopic procedures that divide the muscular bar between the diverticulum and the esophagus, or with surgical approaches in selected cases. Midesophageal and epiphrenic diverticula may require surgical resection, often combined with myotomy (cutting tight esophageal muscle) when an underlying motility disorder is present.
Care is typically coordinated by gastroenterologists, thoracic surgeons (or otolaryngologists, particularly for Zenker diverticulum), and primary care clinicians. Imaging findings are interpreted alongside the patient’s symptoms, motility testing, and overall health.
Red flag symptoms include severe or rapidly progressive difficulty swallowing, recurrent aspiration pneumonia, severe chest pain, vomiting blood, black or tarry stools, significant unintended weight loss, persistent vomiting, or fever and chills with swallowing difficulty. These warrant prompt medical evaluation.