Esophageal Diverticulitis: A Rare Cause of Chest Pain and Worsening Dysphagia

Abstract

Purpose: Esophageal diverticula may occur near the midpoint of the esophagus (traction diverticulum) or immediately above the LES (epiphrenic diverticulum). Epiphrenic diverticula are rare and most commonly found in patients with esophageal motility disorders. Although usually asymptomatic, patients with esophageal diverticula can present with chronic dysphagia and regurgitation. Esophageal diverticulitis is a rare complication, with only 1 prior case report in the literature. We present the 2nd reported case of esophageal diverticulitis as a cause of atypical chest discomfort and worsening dysphagia. A 38 year-old Hispanic woman with a history of hepatitis C infection and thyroiditis presented with fevers and chest pain. The patient reported 8 years of stable intermittent dysphagia to solid foods. She developed 2 weeks of burning epigastric pain and discomfort unrelieved by H2 blocker or PPI therapy. This was followed by 2 weeks of chest pain associated with daily fevers and chills. Over this time her dysphagia worsened to include both solids and liquid foods and she concomitantly experienced a 10-pound weight loss. She denied associated nausea, vomiting, or regurgitation of food. She denied a history of smoking or alcohol use and her family history was unremarkable. Physical examination revealed mild epigastric tenderness. An upper GI series demonstrated multiple irregular epiphrenic diverticula. A subsequent upper endoscopy revealed three diverticula in the distal esophagus, one of which contained an irregular and friable lining with severe inflammation. A CT scan of the chest revealed a large phlegmon around the hiatus consistent with esophageal diverticulitis and mediastinitis. She was admitted to the hospital, made NPO and administered TPN and IV antibiotics. She was then referred for surgical management. Intraoperatively, 2 diverticula were noted; the larger of the two had perforated and was embedded in a mass of inflammation at the level of the hiatus extending towards the left lobe of the liver. The phlegmon seemed to incorporate both vagus nerves. Also, there was a sinus tract from the diverticulum to the proximal stomach, just below the GE junction. The patient underwent successful excision of the perforated esophageal diverticulum as well as a long esophagomyotomy. Post-procedure she complained of early satiety and bloating, which later resolved. After several weeks she was able to resume a normal diet and tolerate both liquids and solids. This case illustrates an extremely rare complication of esophageal diverticula. Epiphrenic diverticulitis should be considered in the differential diagnosis of chest pain and worsening dysphagia.