Endoscopic management of a bleeding Zenker's diverticulum: A case report

Bleeding from a Zenker's diverticulum is a rare occurrence, and currently no formal guidelines exist for its management. It is a potentially life-threatening condition and an important consideration in the differential diagnosis of haemoptysis or haematemesis.

A 63-year-old man presented with haemoptysis and haematemesis while on dual antiplatelet therapy for a recent NSTEMI. After resuscitation he underwent a CT angiogram which demonstrated an active contrast blush and pooling of contrast in a pharyngeal diverticulum. At endoscopy a large Zenker's diverticulum was encountered which contained an ulcerated area with general oozing of blood from multiple points and a single brisk bleeding point. Haemostasis was achieved with two syringes of a topical haemostatic agent.

Less than 15 case reports exist in the literature of this clinical entity, and fewer still have been managed successfully via endoscopic methods. The pathophysiology is unclear however may be related to antiplatelet agents exerting a topical effect after lodging in the diverticulum, causing ulceration, diverticulitis and bleeding. Early diagnosis can be challenging as patients may seem to present with haemoptysis, and delay to prompt diagnosis may further delay management.

This is the first Australian case report of bleeding from a Zenker's diverticulum who underwent successful endoscopic management. It highlights the diagnostic dilemma presented by this clinical entity and the subsequent impacts on management. Endoscopic haemostasis is an ideal intervention either as a definitive procedure in elderly patients unfit for surgery, or initial management as a bridge to surgery.