• 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
• 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
– Aspiration pneumonia
– Lung abscess
• Observation is sufficient for small asymptomatic diverticula
• Upper esophageal myotomy is required for symptomatic patients
• Surgical diverticulectomy is needed in most cases
Content adapted from CURRENT Medical Diagnosis & Treatment 2014.
• 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
• 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)
• 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
• 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
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