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MANUSCRIPT   CENTRAL 338 

 

 
 

Clinical Medicine Insights 
 

DOI: https://doi.org/10.52845/CMI/2022-3-4-1  

CMI 03 (04), 338−342 (2022)                                                                                                                                      
ISSN (O) 2694-4626

 

Case Report                                                                    Open Access Journal                                     

                                                                                                                              

A Giant Zenker’s Diverticulum Revealed by Dysphagia a Rare Case Report 

Houda Tahiri
1
, Nawal Kabbaj

2
, Mouna Salihoun

3, 
Mohamed AcharkI

4
   

Corresponding Author: Houda Tahiri 

1
Intern in gastroenterology, 

Department of gastroenterology 

‘EFD-HGE’ – Mohamed V 

University, Rabat, Morocco. 

2
PhD of gastroenterology, Depart-

ment of gastroenterology ‘EFD-

HGE’ – Mohamed V University, 

Rabat, Morocco. 

3
PhD of gastroenterology, Depart-

ment of gastroenterology ‘EFD-

HGE’ – Mohamed V University, 

Rabat, Morocco. 

4
MD in gastroenterology, Depart-

ment of gastroenterology ‘EFD-

HGE’ – Mohamed V University, 

Rabat, Morocco. 

 

 

 

Introduction

Zenker’s diverticulum (ZD) is a rare condition [1] 

first described by Abraham Ludlow in 1769 [2]. 

However, it was Friedrich Von Zenker, a german 

pathologist, who recognized that ZD results from 

increased intra-pharyngeal pressure [3]. It is 

located proximal to the upper eosophageal 

sphincter ( UES ) usually on the posterior 

hypopharyngeal wall [3]. it rarely occurs before 

the age of 40 years [4]. The first and most 

common symptom is a progressive dysphagia, but 

can have many severe consequences [5]. The 

mainstay of the treatment of ZD  has been surgery 

for a long time, however endotherapy using 

flexible endoscopes has evolved over the last 

years [6]. 

We report this case, with a review of the literature, 

to recall the clinical, endoscopic and radiological 

charesteristics of ZD with the different therapeutic 

modalities. 

Case Report  

A 58 years old man, with a history of chronic 

smoking, presented  a progressive dysphagia for 

over 10 years that initially started for solid food 

and later fluids, regurgitation  of undigested food,  

and chronic cough. He had no odynophagia but 

noticed some weight loss. The patient had no 

Abstract 

Zenker’s diverticulum, which is an alimentary tract pouch localized in 

the area of the upper esophageal sphincter, constitutes a rare 

condition. It’s even rarer when its size exceed 7cm. Most patients are 

elderly and the aetiology remains unknown. The diagnosis is easily 

established based on radiogram with barit and esophago-gastro-

duodenoscopy.  Treatment has been for a long time surgical. Recently, 

endoscopic treatment has becoming increasily popular and is the 

treatment of choice of many hospital centers for its good results and 

low morbidity.  

We highlight, in this paper, the importance of considering the 

diagnosis of Zenker’s diverticulum in clinical practice, not only due to 

the severe consequences, but also due to the existence of effective 

therapeutic methods when diagnosed.  

Key words : Zenker’s diverticulum, dysphagia, surgery, endoscopic 

treatment 

Conflict of interest : There is no conflict of interest. 
Copyright : © 2021 The Authors. Published by Medical Editor and 

Educational Research Publishers Ltd. This is an open access article 

under the CC BY-NC-ND license (https://creativecommons.org/lic 

enses/by-nc-nd/4.0/). 

https://creativecommons.org/lic%20enses/by-nc-nd/4.0/
https://creativecommons.org/lic%20enses/by-nc-nd/4.0/


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similar condition in his family members. During 

clinical examination, the general condition of the 

patient was preserved. He was slighty pale but the  

cardiovascular and abdominal examination were 

normal. Lymph node areas were normal too.  

An upper gastrointestinal endoscopy was 

performed, revealing a large oesophageal 

diverticula at 15cm of the oral cavity with a 

normal mucosa ( Figure 1 ). 

 
Figure 1 :  Endoscopic photos of the patient revealing : Left : (a) Zenker’s diverticulum entrance (b) 

Esophagus entrance. Right : the fundus of the Zenker’s diverticulum. 
 

The oesophageal lumen was deviated, making  

very difficult the progress of the endoscope  

through it. A barium swallow was requested, 

revealing a large oesophageal diverticula at the 

height of the fifth cervical vertebra, measuring 

7x6x7cm ( Figure 2 ) and a small amount of 

barium passing through the rest of the distal 

oesophagus.

 
Figure 2 :  Barium swallow revealing the giant Zenker’s diverticulum of the  patient. 



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Given the enormous volume and the duration of 

the diverticulum, and after a discussion with the 

surgical team, the patient was scheduled for a 

diverticulectomy.   

Discussion  

Zenker’s diverticulum is a rare cause of 

dysphagia, but it is the most common 

diverticulum in the upper gastrointestinal tract [5]. 

The incidence rate in the american population is 

believed to be between 0.01% and 0.11% [6]. 

However the true incidence is difficult to establish 

since the number of asymptomatic patient is 

unkown.  

ZD usually occurs between the seventh and eighth 

decades of life, and rarely before  the age of  40 

years [6]. It’s more common in male than female 

[10].  Our patient was a 58 years old man. 

The most common structure where ZD is located 

is Killian’s triangle caracterised by the highest 

susceptibility  to create diverticula for its low 

resistance. Then, the increase of pressure during  

swallowing, pushes esophageal tissue layers 

outside the esophagus to the mediastinum 

retropharyngeal space, forming a pouch with gates 

limited by muscles [7]. A genetic predisposition 

has not been  proven until now [5]. 

 ZD may occur in different positions (Illustration 

1) with most of the time  the entrance at the top 

and the fundus at the bottom, which was the case 

of our patient. This position  is associated with a 

highest risk of retention of ingesta [8].

 
Illustration 1 : Different positions of Zenker’s diverticulum in relation to the esophageal lumen 

 

According to Morton-Bartney’s classification 

(Table 1), diverticula are divided into three 

categories : small diverticula that measures less 

than 2cm, medium diverticula that measures 

between 2cm and 4cm and large  diverticula 

measuring more than 4cm  [10]. 

Table 1: Morton-Bartney’s Classification [10] 

Size of diverticulum Type of diverticulum 

<2cm Small diverticulum 

2-4cm Medium diverticulum 

>4cm Large diverticulum 

 

ZD are more frequently less than 4cm in length 

[9]. The size of our patient’s diverticulum was 

very large measuring 7cm, which is very rare.  

The symptoms are specific and the most common 

one is an increasing dysphagia  (80-90 % ) due to 

esophagus constriction by a filled diverticulum 

[6,11] which was the case of our patient.  

Regurgitations of undigested food are also one of 

the most usual symptoms ( 60% ) and can lead to 

chronic cough, repeated episodes of aspiration and 

some aspiration pneumonia (30-40% ) [6,11]. Our 

patient described regurgitations and chronic cough 

too. However, symptoms can become more severe 

with the weight loss and malnutrition (20% ) 

[6,11]. A higher incidence of carcinoma has been 

noticed (0,4-1,5%) then the diagnostic should be 

suspected when a sudden increase in the severity 

of dysphagia and/or a development of alarm 

symptoms such hematemesis, hemoptysis or local 

pain  occurs [6]. 

Physical examination findings are few and usually 

seen in severe cases. It includes findings of 

malnutrition, voices changes, neck mass and 

crepitus [10,12]. Our patient has a subnormal 

physical examination. 



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The diagnosis is based  on a radiogram with barite 

that reveals a diverticulum filled with contrast on 

the side of the esophagus [13] 

Esopgastroduodenoscopy (EGD) may be useful in 

ZD. However, manometry is not useful in the 

routine diagnostic approach due to catheter 

dislocation during examination impeding the 

proper analysis [5]. Our patient had undergone 

both of EGD and barium swallow to make a 

diagnosis. 

Treatment of ZD depends on diverticulum size 

and clinical manifestation. Asymptomatic patients 

or diverticulum with a size smaller than 1cm do 

not need  a specific treatment [5]. Thus, treatment 

of ZD is indicated for all symptomatic patients, 

expected patients with high morbidity [6].  

There are several therapeutic approaches 

concerning ZD. The surgical one, has been for 

long time the treatment of choice for an 

established pharyngeal pouch [10]. The open 

approach consists of a  diverticulectomy with or 

without a cricopharyngeal myotomy, or a 

diverticulopexy . Unfortunately, pharyngeal pouch 

surgery has long been associated with a risk of 

significant complications such as fistula, infection, 

vocal cord paralysis and aspiration [15]. The 

flexible endoscopic approach, known for its low 

morbidity, is accomplished by a 

gastroenterologist. It is advantageous for high-risk 

elderly patient who can benefit from a brief 

procedure without general anesthesia and the need 

for hyperextension of the neck. It consists of  

severing the septum between the diverticulum and 

esophagus that contain the cricopharyngeus. The 

division of the septum allows food and liquid to 

flow out of the diverticulum into the esophagus 

rather to lodge within the diverticulum [16]. Three 

principal techniques are employed : needle-knife 

incision, argon plasma coagulation or monopolar 

coagulation using forceps. Several case series 

have demonstrated the efficiency and safety of 

cricopharyngeal myotomy using a flexible 

endoscopic approach [16,17].However, larger 

diverticula (>3cm) may requires  several 

procedures because of 1,5-2cm incision performed 

in multiple sessions. Some rare complications can 

follow flexible endoscopic therapy, it includes 

throat pain, aspiration, perforation and bleeding 

[6].The endoscopic approach allows a clinical 

resolution in 84%  to 96% of cases in one month 

depending on differents studies [18, 19, 20] . The 

surgical approach, in comparison with the 

endoscopic treatment, is associated with higher 

morbidity and a longer period of hospitalization ( 

5-6 days vs 1-2 days ). The oral feeding is 

implemented after 5-6 days in comparison with 2 

days after an endoscopic procedure [5]. Thus, the 

endoscopic approach is interesting for its low 

morbidity and  low cost [5].  

However, it should be noted that despite of 

attractiveness of the endoscopic treatment of 

Zenker diverticulum, we must adapt the type of  

treatment to the case of the patient and the 

characteritics of the diveticulum. Thus, surgery 

treatment remains an option which was the case 

with our patient. 

Conclusion  

ZD is an anatomic abnormality with a wide range 

of symptoms. Its presence should always be 

considered in clinical practice especially in case of 

dysphagia.  Effective therapeutic methods, as the 

endoscopic myotomy, are interesting for its safety 

and efficiency. However, the surgical treatment 

remains an option, especially for the giant 

Zenker’s diverticulum. 

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6.

 

How to Cite Tahiri, H., Salihoun, M., 

Acharki, M., & Kabbaj, N. (2022). A Giant 

Zenker’s diverticulum revealed by 

dysphagia. Clinical Medicine Insights, 3(4), 

338–342. https://doi.org/10.52845/CMI/2022-

3-4-1 


