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Case 377

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A 59-year-old woman presented with approximately 25 years of progressive dysphagia to liquids and solids, without investigation or previous treatments. History of mild persistent asthma that worsened in the last few months, with loss of weight and frequent crisis of dyspnea and regurgitation, especially after meals. Barium swallow is shown (images 1 and 2).

Considering the clinical and radiological findings, what is the most likely diagnosis?

a) Sliding hiatus hernia

25%

b) Paraesophageal hernia

25%

c) Megaesophagus

25%

d) Epiphrenic diverticulum

25%
   

Image Analysis

Image 1: Barium swallow, anteroposterior view, patient in orthostatism. Posterolateral sac-like projection at the right side of the distal thoracic esophagus, with progression of the oral contrast throughout the wide communication orifice.

 

Image 2: Barium swallow, oblique view, patient in orthostatism. Posterolateral sac-like projection at the right side of the distal thoracic esophagus with wide communication orifice. The complete evaluation didn't show communication with the fundus of the stomach or the esophagogastric junction.

Highlights

      - Esophageal diverticula are sac-like outpouching of the esophageal mucosa mainly caused by abnormal motility;

      - Epiphrenic diverticula are rare, usually asymptomatic and progressive;

      - When symptomatic, dysphagia to liquids and solids, heartburn and regurgitation can be present, with worsening of the symptoms after meals;

      - Barium swallow is the main study to confirm the diagnosis. Manometry evaluates possible motility disorders and upper endoscopy evaluates possible associated lesions and neoplasms;

      - Surgical treatment is indicated for patients with severe dysphagia, complications or refractory symptoms.

References

      - Townsend, Beauchamp, Evers, Mattox. Sabiston Tratado de Cirurgia. 19th edition. 2014.

      - Eckardt VF, Hoischen T, Bernhard G. Life expectancy, complications, and causes of death in patients with achalasia: results of a 33-year follow-up investigation. Eur J Gastroenterol Hepatol. 2008.

      - Santos, M, Akerman D, Santos, C. Giant esophageal epiphrenic diverticulum: presentation and treatment. Einstein (São Paulo). 2017, Oct.

      - Killic A, Schuchert, M. Surgical Management of Epiphrenic Diverticula in the Minimally Invasive era. Journal of the Society of Laparoendoscopic Surgeons (JSLS). 2009 Jun.

      - Abdollahimohammad, A. Epiphrenic esophageal diverticula. Journal of research in Medical Sciences (JUMS). 2014 Aug.

      - D'Ugo D, Cardillo G, Granone P, et al. Esophageal diverticula. Physiopathological basis for surgical management. Eur J Cardiothorac Surg 1992.

Author

Lara Hemerly De Mori, 4th year medical student at Universidade Federal de Minas Gerais (UFMG)

E-mail: larahemerly[at]gmail.com

Supervisor

Professor Marco Antônio Gonçalves Rodrigues, surgeon and associated professor of the Department of Surgery at UFMG

E-mail: magro.mg[at]terra.com.br

 

Professor Júlio Guerra Domingues, radiologist and professor of the Department of Anatomy and Image at UFMG

E-mail: jgdjulio[at]gmail.com

Reviewers

Felipe Lopes, Jhonatas Pereira Santos, Larissa Gonçalves Rezende, Gustavo Vargas Borgongino Monteiro

Translated by

Gabriella Yuka Shiomatsu, 5th year medical student at UFMG

E-mail: gabriellashiomatsu[at]gmail.com

Test question

(EBSERH - Antônio Pedro University Hospital HUAP - 2019) Regarding esophageal diverticula (ED), choose the right option.

 

 

a) Traction ED typically arise from the distal esophagus.

25%

b) Zenker's diverticula more than 5 centimeters long are treated with cricopharyngeal myotomy.

25%

c) Endoscopic treatment must be discarded for ED between two and five centimeters.

25%

d) Barium swallow is the best diagnostic tool to identify epiphrenic ED.

25%

e) Epiphrenic ED are mainly found in the proximal esophagus.

25%
   

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