Zenkerʼs Diverticulitis Secondary to Alendronate Ingestion: A Rare Cause of Recurrent Dysphagia

Abstract

Purpose: We describe a 79-year-old female patient who developed acute dysphagia/odynophagia secondary to what we believe to be a caustic injury to a large Zenker's diverticulum associated with chronic alendronate use. The patient was admitted with severe dysphagia and odynophagia of at least one week's duration. She was unable to comfortably swallow solids or liquids, although she could handle her secretions, and she was admitted with dehydration and modest weight loss. She had experienced a similar episode 10 months prior to admission and had a long history of vague symptoms of dysphagia. On endoscopy, a large and markedly inflamed Zenker's diverticulum was identified. However, there was no visual esophageal mucosal injury within the tubular esophagus. Alendronate therapy was discontinued, parenteral nutrition was initiated, and the patient's symptoms resolved within one week. She was able to resume her baseline diet subsequently. Discussion: Bisphosphonate therapy is commonly used to treat osteoporosis, and is therefore an increasingly prevalent component of the medication list of elderly patients in particular. These medications may cause significant caustic injury and are therefore administered with strong cautions and warnings in the setting of dysphagia, or known structural abnormalities of the esophagus. In particular, the tablets may become entrapped within a diverticulum and lead to intense acute inflammatory changes. Conclusions: Zenker's diverticulae, when present, represent a contraindication to oral bisphosphonate therapy. When patients who complain of dysphagia are evaluated for their suitability to receive oral biphosphonate therapy, care should be taken to evaluate not only the tubular esophagus, but also to exclude a Zenker's pharyngeal diverticulum with appropriate contrast imaging.