Retained Pills in a Zenkerʼs Diverticulum

Abstract

Zenker's Diverticulum (ZD) is a false diverticulum resulting from an outpunching of the mucosa and submucosa through a naturally weak muscular area in the posterior pharynx known as killian's triangle. Here we present a case of dysphagia as a result of retained pill remnants in the Zenker's diverticulum. A 93-year-old female presented to the emergency department with reports of the sensation of a pill being lodged in her throat right after she took her morning pills; vitamin C and lisinopril. The sensation persisted. She did drink liquids afterwards and had been able to swallow her saliva with no difficulty. This is the first time she had such symptoms. She denied odynophagia, regurgitation of food and symptoms of respiratory tract infection. The patient's last esophagogastroduodenoscopy (EGD) was done a year prior for Gastroesophageal reflux disease which showed hiatal hernia. Physical examination and laboratory blood tests were unremarkable. Soft tissue x-ray showed oval shaped lucency projecting in the proximal esophagus at the level of C5-C6 and hence why the patient was evaluated by ENT for a laryngoscopy which could not visualize the pill. The patient's symptoms persisted post operatively and Gastroenterology were consulted. The patient was taken for upper GI endoscopy, initially during the procedure, the scope could not be negotiated in the esophagus and after retracting the scope, Zenker's diverticulum was visualized with pill remnants seen within. In this case, Zenker's Diverticulum was discovered via endoscopy. Interestingly, she had an EGD for Gastroesophageal reflux disease within a year that showed hiatal hernia only. Since ZD is an uncommon defect in the elderly population, few cases have been reported. This is possibly due to the fact that they are usually clinically silent. ZD should be observed carefully with a barium swallow study, especially in elderly patients with dysphagia, recurrent aspiration with an unknown cause and regurgitation. In emergency cases, one should take note of the wide differential of the given presentation to decrease the risk of procedure complication, such as perforation. Many different surgical and endoscopic treatment options exist, none of them have proven superiority. Although Endoscopic techniques are effective and have a low rate of recurrence, the optimal treatment option remains a debate.This patient, given her advanced age and her goals of care, decision was made to pursue conservative management.Figure: Soft tissue x-ray showing oval shaped lucency projecting in the proximal esophagus at the level of C5-C6. (Anterior View).Figure: Soft tissue x-ray showing oval shaped lucency projecting in the proximal esophagus at the level of C5-C6. (Lateral View).