Esophageal diverticula

Last updated: June 26, 2023

Summarytoggle arrow icon

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 Zenker diverticulum).

Epidemiologytoggle arrow icon

  • Rare diverticula compared to other gastrointestinal sites [1]
  • Peak incidence: older male individuals [2]
  • Zenker diverticulum is the most common type. [3]

Epidemiological data refers to the US, unless otherwise specified.

Classificationtoggle arrow icon

Esophageal diverticula are classified according to their localization, histology, and pathophysiology. [1]


  • Upper esophageal diverticulum
  • Middle esophageal diverticulum: diverticulum at the tracheal bifurcation
  • Lower esophageal diverticulum: epiphrenic diverticulum

Zenker diverticulum arises from the hypopharynx but is classified as an esophageal diverticulum.

Histology [2]


Pathophysiologytoggle arrow icon

Clinical featurestoggle arrow icon

Symptoms arise if a diverticulum becomes large enough to retain food and/or saliva.

Older MIKE has bad breath: Older, Male individuals, Inferior pharyngeal constrictor, Killian triangle, Esophageal dysmotility, halitosis.

Diagnosticstoggle arrow icon

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 [2]

Barium swallow with videofluoroscopy is the first-line test for diagnosing esophageal diverticula, and it may also show any associated aspiration and/or regurgitation. [7]

Endoscopy [2]

Esophageal manometry [2]

  • Indications: all patients with middle or lower esophageal diverticula, even if asymptomatic
  • Findings: evidence of an underlying motility disorder

Treatmenttoggle arrow icon

Surgical treatment is indicated for patients with symptomatic esophageal diverticula and can be considered for asymptomatic diverticula ≥ 2 cm. [2]

Zenker diverticulum [8]

  • Approaches
  • 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 [2]
    • Diverticulotomy: division of the septum that separates a diverticulum from the physiological esophageal lumen
    • Diverticulectomy: resection of a diverticulum [2]
    • 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 [2]

Middle and distal esophageal diverticula are usually small and asymptomatic. Focus treatment on associated underlying conditions. [2]

Complicationstoggle arrow icon

We list the most important complications. The selection is not exhaustive.

Referencestoggle arrow icon

  1. Achkar E. Esophageal Diverticula. Gastroenterol Hepatol (N Y). 2008; 4 (10): p.691-693.
  2. Townsend CM Jr, Beauchamp RD, Evers BM, Mattox KL. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. Elsevier ; 2016
  3. Bhatt NK, Mendoza J, Kallogjeri D, Hardi AC, Bradley JP. Comparison of Surgical Treatments for Zenker Diverticulum. JAMA Otolaryngol Head Neck Surg. 2021; 147 (2): p.190.doi: 10.1001/jamaoto.2020.4091 . | Open in Read by QxMD
  4. Andreas Anagiotos, Simon Florian Preuss, Juergen Koebke. Morphometric and anthropometric analysis of Killian's triangle. Laryngoscope. 2010: p.NA-NA.doi: 10.1002/lary.20886 . | Open in Read by QxMD
  5. Ballehaninna UK, Shaw JP, Brichkov I. Traction esophageal diverticulum: a rare cause of gastro-intestinal bleeding. SpringerPlus. 2012; 1 (1): p.50.doi: 10.1186/2193-1801-1-50 . | Open in Read by QxMD
  6. Ryan Law, David A. Katzka, Todd H. Baron. Zenker's Diverticulum. Clinical Gastroenterology and Hepatology. 2014; 12 (11): p.1773-1782.doi: 10.1016/j.cgh.2013.09.016 . | Open in Read by QxMD
  7. Weusten BLAM, Barret M, Bredenoord AJ, et al. Endoscopic management of gastrointestinal motility disorders – part 2: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2020; 52 (07): p.600-614.doi: 10.1055/a-1171-3174 . | Open in Read by QxMD
  8. Yong Yuan, Yong-Fan Zhao, Yang Hu, Long-Qi Chen. Surgical Treatment of Zenker's Diverticulum. Dig Surg. 2013; 30 (3): p.207-218.doi: 10.1159/000351433 . | Open in Read by QxMD
  9. Choi AR, Chon NR, Youn YH, Paik HC, Kim YH, Park H. Esophageal cancer in esophageal diverticula associated with achalasia.. Clinical endoscopy. 2015; 48 (1): p.70-3.doi: 10.5946/ce.2015.48.1.70 . | Open in Read by QxMD

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