Esophageal diverticula are abnormal pouches that arise from the wall of the esophagus. They most commonly occur in older men and are classified based on localization, pathophysiology, and histological findings. The most common type of esophageal diverticulum is a posterior outpouching of the hypopharynx, commonly referred to as a Zenker diverticulum. Esophageal diverticula are caused by either an underlying motility disorder that exerts high intraluminal pressure on a weak esophageal wall or forces pulling on the outside of the esophagus. The clinical presentation varies with pouch size and localization, with the most common symptoms being dysphagia, regurgitation, retrosternal pain, and pulmonary symptoms secondary to aspiration. The diagnosis is confirmed by barium swallow. Surgical treatment is rarely required and only recommended in symptomatic patients (primarily those with ).
Esophageal diverticula are classified according to their localization, histology, and pathophysiology. 
- Upper esophageal diverticulum
- Middle esophageal diverticulum: diverticulum at the tracheal bifurcation
- Lower esophageal diverticulum: epiphrenic diverticulum
- True diverticula: All layers of the esophageal wall protrude.
- False diverticula: Increased intraluminal pressure causes only the mucosa and submucosa to bulge through weak points in the muscularis (e.g., in Zenker diverticulum).
- Inadequate relaxation of the esophageal sphincter (e.g., caused by achalasia or spastic motility) and increased intraluminal pressure → outpouching of the esophageal wall → pulsion diverticulum
- Inflammation of the mediastinum with scarring and retraction (e.g., secondary to tuberculosis or fungal infection) → traction diverticulum 
Symptoms arise if a diverticulum becomes large enough to retain food and/or saliva.
- Upper esophageal diverticula (e.g., Zenker diverticulum)
- Middle esophageal and epiphrenic diverticula
Obtain imaging studies to diagnose esophageal diverticula in patients with supportive clinical features. Based on initial findings, consider endoscopy and esophageal manometry to identify concomitant esophageal disorders.
Imaging studies 
Barium swallow with videofluoroscopy (best initial test)
- Diagnostic finding: a contrast-filled pouch protruding from the esophageal wall
- Additional findings may include:
- Esophageal motility disorder
- Transcutaneous ultrasound: Consider for patients who struggle to swallow contrast or those with a palpable neck mass. 
- Indications: all patients with middle or lower esophageal diverticula 
- Indications: all patients with middle or lower esophageal diverticula, even if asymptomatic
- Findings: evidence of an underlying motility disorder
Surgical treatment is indicated for patients with symptomatic esophageal diverticula and can be considered for asymptomatic diverticula ≥ 2 cm. 
Procedures: based on diverticulum size and the chosen approach (i.e., endoscopy or open surgery)
- Cricopharyngeal myotomy: incision of the cricopharyngeal muscle (the main component of the upper esophageal sphincter) to relieve esophageal obstruction; indicated for most patients 
- Diverticulotomy: division of the septum that separates a diverticulum from the physiological esophageal lumen
- Diverticulectomy: resection of a diverticulum 
- Diverticulopexy: suspension of a diverticulum onto the hypopharyngeal wall
- Diverticular inversion
- Other options include stapling, electrocautery, or CO2 laser treatment.
- Goal: to reduce pressure in the upper esophageal sphincter by removing or isolating the diverticulum
Other diverticula 
- Symptomatic or diverticulum ≥ 2 cm: Consider surgical intervention (e.g., diverticulopexy).
Middle and distal esophageal diverticula are usually small and asymptomatic. Focus treatment on associated underlying conditions.