Zenker's Diverticulum

• Mucosal outpouching posteriorly between the Thyropharyngeus and Cricopharyngeus muscle (Kilian triangle).
• Pseudodiverticula.
• MC esophageal diverticula
Pathophysiology -
• Neuromuscular incordination
• Incomplete CP muscle relaxation
• Elevated resting tone of the entire upper esophageal sphincter
• Loss of CP muscle elasticity

Clinical Features -
• Dysphagia
• Chronic cough
• Age >50 years
• Halitosis
• Regurgitation
Association - Cervical webs (in 50%cases)
Fibrosis around diverticula is very common

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Diagnosis -
• Barium swallow - posterior midline pouch greater than 2 cm in diameter usually results in symptoms.

• Flexible endoscopic evaluation of swallowing (FEES)
• Endoscopy - to exclude presence of SCC.

Complications -
• Aspiration, Lung abscess, Pneumonia

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Management -
• Small (< 2 cm) lesions - no intervention
• Intermediate to large diverticula (2-6 cm) - open diverticulectomy with CP myotomy or by endoscopic diverticulotomy.
• Very large diverticula (> 6 cm) are best managed with excision with CP myotomy or a diverticulopexy with CP myotomy.
• Most common open procedure - diverticulectomy with CP myotomy
• Currently preferred treatment is endoscopic stapling (i.e. diverticulotomy with staples ) - Dohlman Procedure.

Achalasia Cardia

• Failure of Lower Esophageal Sphincter to relax during swallowing and absence of esophageal peristalsis.
• Affects both LES & smooth muscles of esophagus.

Pathogenesis -
• Due to progressive inflammatory destruction of inhibitory myenteric neurons in Auerback's plexus.

Clinical features -
• Triad - Dysphagia, Regurgitation, and Weight loss.
• Chest pain
• Nocturnal coughing.
• Allgrove syndrome - Achalasia, Alacrima & Addison's disease


Diagnosis -
• Barium swallow - Bird beak, Pencil tip or Rat tail sign.

• Mecholyl test +ve.
• CCK test +ve.
• Manometry - Gold standard.
Findings - Incomplete LES relaxation, increased resting LES tone, and lack of peristalsis of the esophagus.
• Pressure of LES <26 mm Hg is normal, >100 is considered achalasia, > 200 is nutcracker achalasia.
• Prolonged esophageal pH monitoring to rule out GERD.

Treatment -
• Initial treatment should be pneumatic dilation or laparoscopic surgical myotomy with a partial fundoplication.

• Botox - Botulinum toxin therapy is recommended for patients not suited to PD or surgery.
Limited success rate & high reoccurence.

• Medical therapy - Subligual Nitroglycerine, Nitrates, CCB. (used primarily in elderly patients who have contraindications to either pneumatic dilatation or surgery or in case of failed botox therapy)

• Lap Heller Myotomy with partial anterior fundoplication - Surgery of choice.
• Peroral endoscopic myotomy (POEM) - 50% show gerd
• Toupet or Dor fundoplication (to prevent GERD)

Important - In current practice, a partial anterior fundoplication is more frequently performed since it is simpler to perform and covers the exposed esophageal mucosa.

Congenital Diaphragmatic Hernia (Bochdalek Hernia)

A congenital diaphragmatic hernia (CDH) occurs through an embryologic defects in the diaphragm.

Various types of CDH -
• Bochdalek hernia
• Morgagni hernia
• Diaphragm eventration and
• Central tendon defects of the diaphragm

Pathogenesis -
There are 4 basic  embryologic components responsible for formation of the diaphragm -
• Septum transversum
• Two pleuroperitoneal folds
• Cervical myotomes
• Dorsal mesentery

Failure of the development of the pleuroperitoneal folds and subsequent muscle migration is the main cause of CDH.

Malformation of the diaphragm allows the abdominal organs to herniate into the defect and hinders ipsilateral lung development.


Bochdalek hernia - It is posterolateral defects of the diaphragm, resulting in either failure in the development of the pleuroperitoneal folds or absent migration of the diaphragmatic musculature.

About 90% patients present in the neonatal period or within the first year of life. These cases have a mortality of nearly 50%. Most of the morbidity and mortality of CDH is due to hypoplasia of the lung and pulmonary hypertension on the affected side. Hence, early diagnosis and management is important for survival.

Most of Bochdalek hernias (80–85%) occur on the left side of the diaphragm.


Presentation -
Right-sided heart; decreased breath sounds on the affected side; scaphoid abdomen; bowel sounds in the thorax, respiratory distress, and/or cyanosis on auscultation.
Classical triad - Respiratory distress, Dexrocardia, Scaphoid abdomen.
Main cause of morbidity and mortality - Pulmonary hypoplasia and pulmonary hyerptension.

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Diagnosis -
• Low levels of maternal serum alpha-fetoprotein (AFP)
• X-ray - bowel and stomach in the chest cavity and shift of the mediastinum (usually to the right)
• USG criteria -
1. Polyhydramnios
2. Absent or intrathoracic stomach bubble
3. Mediastinal and cardiac shift away from the side of herniation.
4. Fetal hydrops (rare)


Treatment -
• High frequency oscillatory ventilation
• ECMO (reserved for individuals whose condition fails to improve with both HFOV and conventional mechanical ventilation)
• Early repair is not indicated and should be delayed until the infant is better prepared to survive the operation.
• For treatment of CDH in the neonatal period, a subcostal incision is used. In primary repair of the hernia. The abdominal contents are reduced, and the edges of the diaphragm are then approximated with nonabsorbable suture.
• For large defects prosthetic material such as expanded polytetrafluoroethylene (ePTFE) or polypropylene is used.