Esophageal motility disorders associated with epiphrenic diverticula: a systematic review using high-resolution...

Epiphrenic diverticula (ED) are rare outpouchings of the lower esophagus, usually occurring due to abnormal esophageal muscle activity. Although high-resolution manometry (HRM) has significantly improved our understanding of the underlying motor abnormalities, a comprehensive overview of HRM findings in these patients is still lacking. We conducted a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines, based on a pre-registered protocol (PROSPERO: CRD42021233228). PubMed, Web of Science, and Scopus were comprehensively searched from inception through May 31, 2025, for studies reporting HRM findings in adult patients with epiphrenic diverticula. Data were collected on patient demographics, diverticulum features, manometric metrics, and Chicago Classification diagnoses. Risk of bias was evaluated with the Joanna Briggs Institute appraisal tools. Due to significant heterogeneity in clinical and methodological aspects across studies, results were summarized narratively, rather than through meta-analysis. Twenty studies involving 226 patients with ED who underwent HRM during the evaluation of suspected esophageal motility disorders met the inclusion criteria. Abnormal HRM results were observed in 191 patients (84.5%). Achalasia was the most common diagnosis in 114 patients (50%), followed by hypercontractile esophagus in 20 patients (9%), esophagogastric junction outflow obstruction in 14 patients (6%), and distal esophageal spasm in 9 patients (4%), which together made up the main categories. About one in seven patients had normal motility. Some studies suggested a potential link between larger diverticula and higher lower esophageal sphincter pressures or spastic motility patterns; however, due to limited and varied data, consistent correlations could not be confirmed. This review demonstrates that abnormal high-resolution manometric findings are frequently reported among patients with ED undergoing evaluation for esophageal symptoms, with obstructive motility disorders, particularly achalasia being the predominant diagnoses. These findings support routine HRM as part of the pre-treatment evaluation of patients with ED.