1951 Not All Diverticular Bleeds Are Colonic: A Rare Case of Zenker's Diverticulum Bleeding and Endoscopic Treatment

Abstract

INTRODUCTION: Zenker's diverticulum (ZD) is a retropharyngeal pouch formed with herniation through Killian’s triangle. The diverticulum is thought to be developed through traction & pulsion but precise mechanism is unknown. Prevalence estimated to be 0.01–0.11%; ZD is predominantly in adults age >60. ZD is associated with dysphagia, halitosis, regurgitation & cough. But very rarely associated with bleeding - only 7 cases reported in the literature. Aspirin irritation is theorized as the etiology, as all reported cases involved aspirin or other anti-platelet medication. CASE DESCRIPTION/METHODS: A 73 year-old male with history of obesity, GERD, former smoker, & coronary artery disease presented with hematemesis & hemoptysis. 1 week prior to onset of bleeding, he was hospitalized for STEMI requiring intubation which was traumatic with minor bleeding, & he underwent drug eluting stent placement to the left anterior descending artery. He was discharged home on aspirin & clopidogrel. Patient had awakened due to the sensation of liquid pooling in the back of his throat; he cleared this with a cough & noted the liquid to be gross blood. He then had ongoing small volume hemoptysis & hematemesis. He denied dysphagia, NSAID usage & breakthrough reflux symptoms on daily PPI. On exam, tachycardic to 120s, otherwise vitals normal; diaphoretic & pale but otherwise benign exam. Patient’s hemoglobin had decreased from 13.3 g/dL at discharge to 8.7 g/dL in the ER; also notable for blood urea nitrogen of 45 mg/dL. ENT evaluated initially due to complaint of hemoptysis & recent traumatic intubation. Laryngoscopy revealed blood pooling at the esophageal inlet; this could be cleared voluntarily by patient, but it immediately reaccumulated. Otherwise the oropharyngeal exam was normal. EGD was subsequently performed & this revealed large ZD which was filled with fresh blood. This area was lavaged & small ulcer seen at base; multiple clips were placed with successful hemostasis. Further exam of esophagus, stomach & proximal duodenum revealed no additional source. Patient’s bleeding stopped & tolerated resumption of aspirin & clopidogrel without further incident. DISCUSSION: ZD bleeding is an extremely rare event, so treatment modalities may not be readily familiar to most medical staff. We report the third case of ZD bleeding treated with endoscopic hemostasis; all cases have been successful & well tolerated. Traditionally, ZD bleeding has been treated surgically, but this may not be an option in certain populations or situations.