When a large perforation has occurred there is a high risk of mediastinitis and it is best to excise the diverticulum, repair the defect and drain the para-pharyngeal tissues. This was performed in this patient and a post-operative gastrograffin study shows no residual leakage.

A patient presented with increasingly severe dysphagia and a cough. A barium swallow was performed. What does the xray show? What complication of this condition is also demonstrated on the xray?

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There is a high risk of perforation of the diverticulum as the endoscope often passes directly into the diverticulum which is thin-walled.

This barium swallow shows leakage of contrast into the para-vertebral and para-pharyngeal spaces. The CT scan shows the presence of gas in these same spaces.

How is this patient best managed?

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Learning points

• Pharyngeal pouch is a cause of dysphagia and often associated with aspiration.
  
• It usually presents in elderly patients.
  
• There is a very high risk of perforation during upper gastrointestinal endoscopy.
  
• Small leaks can be managed conservatively but a large perforation requires exploration and repair.
  
• In uncomplicated cases, good results can be obtained by endoscopic surgery, using a staple gun which divides the crico-pharyngeal bar and allows the content of the pouch to drain into the oesophagus.

The xray shows a pharyngeal pouch (or Zenker's diverticulum). This is a pulsion diverticulum arising from the posterior wall of the pharynx between components of the inferior constrictor muscles. The weakness is referred to Killian's dehiscence. The patients are usually elderly. Aspiration into the trachea often occurs and this xray shows contrast in the patient's trachea. This gives rise to a chronic cough and may progress to aspiration pneumonia.

Upper gastrointestinal endoscopy was performed in our case. What serious complication can result from endoscopy ?

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From: Shakilur Rahman