Physiopathology of lower esophageal diverticulum and its implications for treatment

This study attempted to define the esophageal motor disturbances and pathogenesis of symptoms in patients with lower esophageal diverticulum. Sixty-five patients were investigated by manometry in addition to roentgenography and endoscopy. Fifty had manometric evidence of abnormal motility, most often diffuse spasm or achalasia. Of the 15 patients with normal esophageal motility, 13 had hiatal hernia, and five of these had a high grade distal esophageal stricture. Pressures in the lower esophagus and lower esophageal sphincter in patients with lower esophageal diverticulum and motor disturbance were the same as for those in matched patients with motor disturbances but no diverticulum. Dysphagia, chest pain and regurgitation were common presenting symptoms. Of 46 patients with dysphagia, only ten had mechanical obstruction to explain this symptom. Of 32 patients with chest pain, only two had ulceration in the diverticulum as a possible cause of pain. We conclude that the development of lower esophageal diverticulum and its symptoms are associated with a motor disturbance of the esophagus in the majority of patients and with an organic obstruction in the minority of patients. The diverticulum itself is usually not the sole cause of the esophageal symptoms, although diverticula can produce symptoms in the absence of other definable conditions. When surgical treatment is indicated, the diverticulum should be excised and the underlying motor or mechanical obstruction should be corrected to prevent serious postoperative complications and recurrence of the diverticulum and its symptoms.