Zenker Diverticulum: The Daily PANCE Blueprint
A 72-year-old man has six months of difficulty swallowing that he localizes to his upper neck. He describes regurgitating undigested food hours after a meal — sometimes onto his pillow at night, followed by coughing — and his wife complains of his bad breath. He reports a gurgling sensation in his neck when he swallows and has lost 6 pounds. There is no odynophagia and no heartburn, and his oral and neurologic examinations are normal. Which of the following is the most appropriate initial diagnostic test?
A. Upper endoscopy
B. Esophageal manometry
C. Barium esophagram
D. 24-hour esophageal pH monitoring
E. CT of the neck with contrast
Answer and topic summary
The answer is C. Barium esophagram
Regurgitation of undigested food hours after eating, halitosis, and a gurgling neck in an older adult is a Zenker diverticulum — an outpouching of mucosa that herniates backward through Killian’s triangle, the weak spot between the inferior pharyngeal constrictor and the cricopharyngeus, when the upper esophageal sphincter fails to relax against a rising pharyngeal pressure. Because it is a pulsion false diverticulum containing only mucosa and submucosa, food collects in the pouch and comes back up undigested, unchanged, and foul — hence the halitosis and the nocturnal aspiration. The initial test is a barium esophagram (ideally with video fluoroscopy), which outlines the pouch, its size, and its neck, and tells the surgeon what to do. Upper endoscopy is the trap: it is not the first test and carries a real risk of perforating the thin-walled pouch, because the scope preferentially enters the diverticulum rather than the true lumen — if endoscopy is done at all, it is done carefully and after the anatomy is known. Manometry may show a poorly relaxing cricopharyngeus but does not image the pouch, pH monitoring is chasing reflux, and CT is not the first-line study. Treatment for symptomatic disease is surgical or endoscopic, and the essential component is a cricopharyngeal myotomy — divide the muscle that caused the problem, or the pouch will simply come back.
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