Massive Upper Gastrointestinal Bleed from Epiphrenic Diverticulum

Abstract

Purpose: Lower esophageal diverticula (epiphrenic diverticula) are outpouchings of the esophagus that retain some or all layers of the esophageal wall. Epiphrenic diverticula are rare causes of significant upper gastrointestinal bleeding. We describe an elderly patient with massive upper gastrointestinal bleeding from an epiphrenic diverticulum. An 86 year old white woman presented with hematemesis after eating pizza. The patient had a longstanding history of dysphagia, as well as coronary artery disease. Medications included apirin 325 mg daily. On arrival the patient was in mild distress with a blood pressure of 102/49 and heart rate of 102, with orthostatic changes. Exam was significant only for brown guaiac positive stool on rectal exam. There was red blood on nasogastric lavage. Lab test results included a hemoglobin of 8.1 g/dL, hematocrit 27.9%, platelets 133,000/ml, wbc count 7,740, and PT 16.1. Chest x-ray showed osteopenia. She was transfused 2 units of packed red blood cells. Emergent endoscopy revealed a diverticulum with a large opening and adherent fresh clot in the lower esophagus, 2 cm proximal to the Z-line. Endoscopic therapy was not attempted since the base of the diverticulum could not be visualized despite extensive lavage. She was successfully managed conservatively with constant infusion proton pump inhibitor. The patient was discharged on pantoprazole with instructions not to resume taking aspirin and at follow-up one month later, she did not have recurrent bleeding. Epiphrenic diverticula occur in the distal 10 cm of the esophagus and are considered to be pulsion diverticula. They are frequently associated with motility disorders, such as achalasia and diffuse esophageal spasm. Symptoms when present include dysphagia, regurgitation, and chest pain. Complications of epiphrenic diverticula include perforation and carcinoma in the diverticulum. Few cases of bleeding have been reported. Bleeding epiphrenic diverticula have been managed, as in our case, with conservative medical therapy alone. Endoscopic treatment with epinephrine followed by thermal coagulation has been described. Surgical management is usually done in the elective setting for symptomatic patients and consists of either resection with myotomy via thoracotomy, or more recently, with minimally invasive treatment with laparoscopic or thoracoscopic diverticulectomy, usually with myotomy and partial fundoplication. In conclusion, bleeding epiphrenic diverticula should be included in the consideration of rare causes of upper gastrointestinal bleeding.