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Key Features

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  • • Protrusion of pharyngeal mucosa develops at the pharyngoesophageal junction between the inferior pharyngeal constrictor and the cricopharyngeus

    • Loss of elasticity of the upper esophageal sphincter, resulting in restricted opening during swallowing, is believed to be the cause

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Clinical Findings

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  • • Dysphagia and regurgitation tend to develop insidiously over years in older patients

    • Initial symptoms include vague oropharyngeal dysphagia with coughing or throat discomfort

    • As the diverticulum enlarges and retains food, patients may note

    • – Halitosis

      – Spontaneous regurgitation of undigested food

      – Nocturnal choking

      – Gurgling in the throat

      – Protrusion in the neck

    • Complications

    • – Aspiration pneumonia

      – Bronchiectasis

      – Lung abscess

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Diagnosis

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  • • A barium esophagogram is the best method to establish diagnosis

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Treatment

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  • • Observation is sufficient for small asymptomatic diverticula

    • Upper esophageal myotomy is required for symptomatic patients

    • Surgical diverticulectomy is needed in most cases

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Content adapted from CURRENT Medical Diagnosis & Treatment 2014.

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Key Features

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Essentials of Diagnosis

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  • • Peptic ulcer disease, may be severe and atypical

    • Gastric acid hypersecretion

    • Diarrhea common, relieved by nasogastric suction

    • Most cases are sporadic; 25% with multiple endocrine neoplasia (MEN) type 1

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General Considerations

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  • • Caused by gastrin-secreting gut neuroendocrine tumors (gastrinomas), which result in hypergastrinemia and acid hypersecretion

    • Gastrinomas cause < 1% of peptic ulcers

    • Primary gastrinomas may arise in the pancreas (25%), duodenal wall (45%), lymph nodes (5–15%), or other locations (20%)

    • Most gastrinomas are solitary or multifocal nodules that are potentially resectable; 25% are small multicentric gastrinomas associated with MEN 1 that are more difficult to resect

    • Gastrinomas are malignant in less than two-thirds; one-third have already metastasized to the liver at initial presentation

    • Screening for Zollinger-Ellison syndrome with fasting gastrin levels indicated for patients with

    • – Ulcers refractory to standard therapies

      – Giant ulcers (> 2 cm)

      – Ulcers located distal to the duodenal bulb

      – Multiple duodenal ulcers

      – Frequent ulcer recurrences

      – Ulcers associated with diarrhea

      – Ulcers occurring after ulcer surgery

      – Ulcers with complications

      – Ulcers with hypercalcemia

      – Family history of ulcers

      – Ulcers not related to Helicobacter pylori or nonsteroidal anti-inflammatory drugs (NSAIDs)

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Clinical Findings

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Symptoms and Signs

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  • • Peptic ulcers in > 90%, usually solitary and in proximal duodenal bulb, but may be multiple or in distal duodenum

    • Isolated gastric ulcers do not occur

    • Gastroesophageal reflux symptoms

    • Diarrhea, steatorrhea, and weight loss secondary to pancreatic enzyme inactivation

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Differential Diagnosis

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  • • Peptic ulcer disease due to other cause, eg, NSAIDs, H pylori

    • Gastroesophageal reflux disease, esophagitis, gastritis, pancreatitis, or cholecystitis

    • Diarrhea due to other cause

    • Other gut neuroendocrine tumor

    • – Carcinoid

      – Insulinoma

      – ...

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