Epiphrenic Diverticulum Mimicking Hiatal Hernia

Abstract

Introduction: Epiphrenic diverticula of the esophagus are associated with concomitant esophageal motility disorders. The primary differential is a hiatal hernia, which is far more common. Symptomatic patients with epiphrenic diverticula exhibit dysphagia, regurgitation and aspiration. While most patients are treated conservatively, some may require diverticulectomy and esophageal myotomy to address the underlying motility disorder. We herein present a case of patient with esophageal perforation due to a large unrecognized esophageal diverticulum. A 48-year-old healthy woman found down at a social gathering was intubated on site and transported to a level one trauma center for acute respiratory distress. On radiology report, the CT PE protocol suggested a large portion of the stomach was in the right chest. There were no signs of acidosis, pneumatosis or pneumomediastinum. Family reported a longterm history of dysphagia for solids and liquids with regurgitation of food for the past six years. Previous workup included a CT of the chest indicative of a large paraesophageal hernia. EGD subsequently was attempted and was incomplete twice due to retained stomach contents, despite preparation with a clear liquid on the day prior to procedure. No esophagram or manometry was found in the patient record. A surgical referral had been provided for symptomatic paraesophageal hernia but he was unable to pursue further evaluation due to financial limitations. An emergent thoracotomy was performed for suspicion of gastric volvulus shortly after the patient was admitted. A large 10 cm perforated epiphrenic diverticulum was found during surgery for which myotomy with resection of the diverticulum was performed. Epiphrenic diverticulum is a pulsion diverticulum, usually located in the distal 10 cm of the esophagus. It is due to the herniation of mucosa and submucosa through the muscle layers of the esophageal wall due to increased pressure in the area of the diverticulum. Misdiagnosis of an epiphrenic diverticulum as a hiatal hernia results in a missed opportunity to address a treatable esophageal disorder. Epiphrenic diverticula are thin walled on CT; in contrast the thick walled hiatal hernias which often exhibit the presence of gastric mucosa and rugae. In addition, epiphrenic diverticula do not cause widening of the esophageal hiatus that is seen in the setting of hiatal hernia. Early recognition and diagnosis of epiphrenic diverticulum is crucial to prevent life threatening complications such as malignancy, obstruction, bleeding and esophageal perforation, as seen in this case.