An Unusual Case of Upper Gastrointestinal Bleeding

Abstract

A 63 year old man with history of diabetes mellitus presented with coffee ground emesis and was found to be in diabetic ketoacidosis (DKA). His coffee ground emesis was self-limited and his DKA was the result of failing to take his prescribed insulin. He denied any abdominal pain, NSAID use, alcohol ingestion, melena or hematochezia. His surgical history was significant for removal of a “benign cyst” from his esophagus. Hemoglobin and hematocrit levels on admission were 12.2 g/dL and 39.5%, respectively. Upper endoscopy was performed and showed a large epiphrenic diverticula with ulceration (image #3). The food content seemed to have eroded the mucosa of the diverticula and caused it to bleed. No visible vessel was found inside the diverticula. Barium esophagogram images confirmed enodsopic findings (Image #1-2). Epiphrenic diverticula are uncommon and has an incidence of 0.015% in the United States (7). Diverticulum of the esophagus can be seen in upper (Zenker diverticula), mid (Traction and Pulsion diverticula) and lower esophagus (Epiphrenic diverticula). 75% to 90% of patients with epiphrenic diverticula have an underlying esophageal motor disorder, rather than a primary anatomic abnormality, as an underlying cause. These motility disorders mainly comprise of achalasia, nut cracker esophagus and diffuse esophageal spasm (DES). Delay in the diagnosis and treatment of symptomatic epiphrenic diverticula can lead to severe complications; including cough, aspiration, gastrointestinal bleeding and malignancy (2).Figure 1Figure 2Figure 3If the diverticula is found incidentally or if it is associated with mild symptoms, conservative management may be considered especially in high surgical risk patients. Surgery is recommended in severe symptomatic cases. The surgical procedure of choice is diverticulotomy plus myotomy and esophageal manomtery prior to any invasive procedure is recommended (3). The addition of an antireflux procedure after the myotomy is an area of ongoing research and debate. Surgery is associated with significant morbidity and mortality as high as 5-9% have been reported and should be performed at high volume centers.