2.  Posterior Diverticulum with the neck originating at a site proximal to the Upper esophageal sphincter  First described by Ludlow in 1767, named for Zenker and von Ziemssen who reviewed the world literature in 1877

3.  Annual incidence of 2 per 100,000  Usually present in age >60  Often age >75  Male predominance  Unclear reason for this

4.  Etiology not entirely clear:  Increased pressures while swallowing, leading to outpouching through naturally weak area of esophagus (Killian’s triangle)  Resistance to swallowing due to abnormalities of the UES  High association with dysphagia (even after repair)  Acid induced esphageal dysmotility  Associated with Barrett’s esophagus in 15-20%  Associated with increased rate of Hiatal Hernia

5.  Halitosis  Regurgitation of undigested food eaten up to 48 hours prior  Cough  Dysphagia  Aspiration  Gurgling in the throat  Appearance of a neck mass  Chronically: Severe cachexia, recurrent Pneumonias

6.  Usually diagnosed with Barium Study  Entire first glass of barrium can fit in diverticulum if large and may be confused with esophageal obstruction  Second diverticulum present in 1-2%  May miss small diverticulum if superimposed in plane with barium column  Helps to rotate the patient during exam to avoid this

7.  Endoscopy  Less often used due to possibility of perforation, however this is rare  May find retained pills, food, saliva.  Must use a forward viewing scope to avoid perforation  Side viewing scopes should be passed over a wire after direct forward visualization

8.  Manometry  Rarely required in patients with Zenker’s  May help with determining pathogenesis of the diverticulum  Associated condidtions  Achalasia  Esophageal dysmotility  Increased pharyngeal pressures during swallowing

9.  Mainstay of treatement is surgical  Open resection  Cricopharyngeal myotomy with diverticulectomy  Cricopharyngeal myotomy without diverticulectomy  One stage excision  2 stage mobilization and then excision at later stage.  Endoscopic  Cutting through the common wall of the diverticulum and esophagus

10.  Aspiration Pneumonia  And all of the complications of pneumonia  Carcinoma of the diverticulum  Ulceration and bleeding of diverticulum if retained aspirin  Perforation of diverticulum  Pneumomediastinum  Mediastinitis  Severe malnutrition – cachexia

11.  Our patient’s main presentation was that of respiratory distress and cachexia.  For all intents and purposes he presented the same way one would expect Advanced Lung cancer to present.  Only later did the dysphagia and regurgitation come to light.

12.  Harrison’s internal Medicine pg. 1854  Up to Date – article on Zenker’s Diverticulum  van Overbeek JJ. Pathogenesis and methods of treatment of Zenker’s diverticulum. Ann Otol Rhinol Laryngol 2003;112:583-593.