Zenker’s Diverticulum: A case study of sorts

Zenker’s diverticulum can be devastating for patients and intervention can carry great risk.

I have a hypothetical patient. He’s not real. Instead, he’s based on a few patients I’ve had recently. Let’s call him Paul. Admitted for aspiration pneumonia with respiratory failure and a history of HTN, dyslipidemia, a-fib, heart failure, cardiomyopathy with AICD, Zenker’s diverticulum, and COPD. He has been back and forth from trach to vent and vent to trach, but is finally stable on trach collar during the day with occasional nocturnal ventilation. Now is my time. I evaluate his tolerance for a speaking valve and small amounts of ice chips. Wet vocal quality with persistent throat clearing and coughing. Poor guy sounds like he’s underwater. I stop after two trials and take a step back. 

Connecting the past with the present 

I reviewed his H&P one more time to try and connect his past to his present. One thing that jumped out at me was his Zenker’s diverticulum (ZD). He had a GI appointment lined up to assess further, but that was before he was admitted to the hospital for aspiration pneumonia. Hm, could there be a connection between ZD and aspiration pneumonia? Did I know enough about ZD to make that kind of determination? If the connection could be made, can we justify moving forward with PO trials? What kind of tests would he need before we make an informed decision? Hey, rabbit hole- here I come! 

What is Zenker’s?

If you haven’t seen or heard of ZD, you can check it out here. In summary, it’s when the posterior esophageal wall pushes out into a little thumb-like pouch typically at or just below the level of the cricopharyngeal segment and is caused by a resistance in cricopharyngeus relaxation (the muscle that makes up the UES). You can already see how this would be problematic. The pouch tends to protrude posteriorly within the esophagus so instead of a bolus making its way cleanly down the “tube,” it gathers in this little pocket. If your esophagus was a Kangaroo then ZD would be its pouch where it keeps its little bolus babies; wanting to keep them safe and sound. The problem though is that it’s not safe and sound. The concern is mostly for hard, crunchy food or small pieces of clusters such as rice or corn. They tend to get cozy with one another in this pouch which is a concern because 1. They stick around like a 22 year old at home without a job (which increases infection risk) and/or 2. Cause esophageal dysmotility with reflux. 

 Connecting the dots 

Let’s connect the dots. Paul has ZD. He was also diagnosed with aspiration pneumonia. Further, his medical complexity could make him vulnerable to further infection. Could the ZD and the pneumonia be connected? Could it have been reflux that went up to the pharynx, larynx, and into the airways and lungs causing pulmonary inflammation? Or maybe anterograde aspiration from a buildup of pressure at the cricopharyngeal segment and pooling of the bolus anteriorly into the larynx? All scenarios are possible. In fact, up to 98% of patients with ZD have dysphagia and aspiration is common. But let’s take a look for ourselves before we start jumping like a kangaroo to conclusions.

You can’t treat what you can’t see

You’ve heard that line before. We already know the risk is high with this patient so attempting any more trials at the bedside won’t give us much more information and it may be at the expense of increasing the risk of respiratory compromise. We need to take a look at what’s going on. My study of choice in this particular situation would be an MBSS. I know, I’m more of a FEES guy and I run a company based on that notion and all, but clinically speaking, when we are concerned about an esophageal issue it helps to, you know, have a view of the esophagus (And you didn’t think you’d learn anything from this blog!). BUT the problem is that it’s very difficult to send critically ill patients out of this facility; a critical care recovery hospital. Our patients tend to be fragile, medically unstable (Paul included), and so transportation is tricky. It can be extraordinarily uncomfortable for the patient and even dangerous at times. Further, leaving the facility and entering another may expose an already overly-burdened immune system to another hospital’s bugs (COVID-19 has made this issue even more apparent). 

1-2-3 Go Team! 

I talked over the pros/cons of MBSS vs FEES with the house physician team, the gastroenterologist, and our surgical team; all of whom agreed that a FEES would be preferable at this time. Along with the obvious benefits of keeping the patient in-house, the patient had a ton of secretions so we wanted to assess this directly before PO trials which is not possible with an MBSS (Yes, we also looked into whether the ZD could be causing the secretions, but surgery ruled this out as there were no signs of cervical inflammation which would be the only indication). I also spoke to the team about examining the ZD itself prior to PO trials. Turned out, nobody found this necessary. Even if we saw a problem through imaging, treatment is typically avoided in older, more fragile patients and that describes Paul pretty well. So we determined that surgical intervention was not clinically indicated. Therefore, without real consideration of invasive intervention, doing another invasive procedure such as an esophagogastroduodenoscopy (EGD) wouldn’t be worth the risks of the test itself. 

The FEES

The FEES was surprisingly uneventful. I believe this was mostly because the patient was given a full week without nocturnal mechanical ventilation prior to the test and had been treated with bronchodilators both of which improved his secretion management in the days leading up to the exam. No penetration, no aspiration, and grossly adequate bolus clearance with the exception of mild residue residing safely in the shelter of the valleculae and pyriform sinuses. No reflux was observed!

Eating with Zenker’s 

We decided to move forward with a puree diet with eventual advancement to soft, moist solids and then finally regular solids over a course of 2 weeks. Pt did well on that for another week prior to discharge to acute rehab. Appetite was good and the feeding tube was discontinued. Thankfully, we didn’t need to provide any invasive interventions for the patient’s ZD. He only presented with occasional globus sensation that resolved with slow pacing and, given his age, he wasn’t a good candidate for surgical intervention anyway. But many are good candidates and do end up requiring intervention for safe and effective meal management…

There are a few different surgical and endoscopic approaches with the aim of eliminating the pouch either by inverting it, fixating it to the rest of the esophagus, or cutting it out completely. Invasive procedures should be the last resort- a decision that is made by looking carefully at the severity of clinical symptoms and weight loss. While quick-fix procedures for ZD sound attractive and are actually around 90% effective, they come with high risks, including perforation and fistula.  Further, ZD tends to affect the elderly, who will be at higher risks during invasive procedures (my patent is 79). So I’m truly hoping we can continue to find ways to help Paul manage potential symptoms in the future without bringing the knife into the equation. 

What I’ve Learned

Over the years, I have learned that the absence of intervention can be as valuable to the patient (if not more so) as high-risk procedures. Of course, it all depends on who the patient is, how severe their condition is, what their goals are, and what their risk tolerance is. Every patient is different. We know this. Taking the time to understand the patient, their risk factors, and their preferences will increase our odds of making a decision that is best for that patient at that moment. Even if the decision means letting the condition go without invasive intervention. This is often hard for medical professionals. We want to do something. Anything, to make things better. But for my theoretical friend, the non-invasive path was one that worked out for the best.

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