1990, The British Journal of Radiology, 63, 221-222
Case reports Giant mid-oesophageal diverticulum: a rare cause of dysphagia By R. J . Etherington, FRCR and *D. Clements, MRCP Departments of Diagnostic Radiology and *Gastroenterology, University Hospital of Wales, Heath Park, Cardiff CF44XW
(Received March 1989 and in revised form September 1989)
Mid-oesophageal diverticula are usually small, asymptomatic and rarely result in complications (Meshkinpour, 1985). We report a case of a giant mid-oesophageal diverticulum which caused dysphagia. The aetiology of these diverticula is discussed. Case report A 91-year-old man presented with a long history of dysphagia and weight loss of over 20 kg. More recently he had developed vomiting and symptoms of nocturnal aspiration. The dysphagia had become severe and he required intravenous fluids to maintain his hydration. The chest radiograph demonstrated an irregular gas lucency inferior to the carina (Fig. 1). There was no evidence of previous tuberculous infection. Barium swallow examination revealed a huge sac arising from the mid-part of the oesophagus and extending to the left and anterior to it. Initially, the sac appeared thick walled (Fig. 2), but on delayed radiographs barium penetrated the food residue within it revealing a thin walled diverticulum. Barium preferentially entered the diverticulum, then overflowed into the distal oesophagus which was Address correspondence to: Dr R. J. Etherington, Senior Registrar, Department of Diagnostic Radiology, University Hospital of Wales, Heath Park, Cardiff CF4 4XW.
Figure 2. Early lateral film from barium swallow showing contrast medium entering the diverticulum. displaced by the diverticulum and demonstrated non-propulsive contractions. Endoscopy confirmed the radiological findings of a large mid-oesophageal diverticulum. The distal oesophagus was macroscopically normal and the endoscope passed readily into the stomach. He was not willing to undergo oesophageal manometry. Surgery was also refused so he was fed enterally via a nasogastric tube.
Discussion Figure 1. Chest radiograph demonstrating an irregular gas lucency in the mediastinum (arrows).
The British Journal of Radiology, March 1990
Oesophageal diverticula may be classified anatomically as pharyngo-oesophageal, mid-oesophageal, intramural and epiphrenic. Classification into traction and pulsion on the basis of the presumed aetiology was first 221
Case report
1990, The British Journal of Radiology, 63, 222-224
suggested by Rokitansky in 1840 (from Meshkinpour, 1985). Mid-oesophageal diverticula are widely thought to be of traction origin; this is based on early observations of an association between tuberculous lymph nodes and diverticula of the adjacent oesophagus. Although diverticula are associated with other causes of mediastinal fibrosis such as treated non-Hodgkin's lymphoma (Barosi et al, 1976) and histoplasmosis (Jenkins et al, 1976), post-mortem studies have failed to demonstrate fibrous adhesions in most cases suggesting that traction is the cause in only a minority. It has also been suggested that oesophageal motility disorders may result in mid-oesophageal diverticula. Kaye (1974) found manometric evidence of significant oesophageal motor dysfunction in 10 out of 12 patients. Similarly, Borrie and Wilson (1980) found motor abnormalities in four of five cases. Other potential explanations include a congenital origin (Borrie & Wilson, 1980) or pseudo-diverticulum due to a walled-off perforation. Mid-oesophageal diverticula are rarely symptomatic (Jordan, 1977; Meshkinpour, 1985) since they are generally small, have wide necks and the sac is usually higher than the neck of the diverticulum, preventing the retention of food (Meshkinpour, 1985). Our case is unusual because the diverticulum was symptomatic. This may be partly a result of its large size causing oesophageal displacement. In addition, the position of the sac predominantly below the level of its neck resulted in preferential filling of the diverticulum.
The aetiology of this diverticulum is unclear; although formal manometric studies could not be performed the uncoordinated distal oesophageal contractions did not delay the passage of barium, so they may be clinically insignificant. There was no evidence of previous tuberculosis and no history to suggest previous oesophageal perforation. A mid-oesophageal diverticulum should be considered in the differential diagnosis of dysphagia, and as a cause of an abnormal gas collection in the middle mediastinum on plain radiographs. Barium swallow readily confirms the diagnosis. References BAROSI, G., MORANDI, S. & ASCARI, E., 1976. On a case of
esophagus Remission 219-223.
involvement by non-Hodgkin's lymphoma. by chemotherapy alone. Hematologica, 61,
BORRIE, J. & WILSON R. L. K., 1980. Oesophageal diverticula:
principles of management and appraisal of classification. Thorax, 35, 759-767. JENKINS, D. W., FISK, D. E. & BYRD, R. B., 1976. Mediastinal
histoplasmosis with esophageal abscess. Gastroenterology, 70, 109-111. JORDAN, P. H., 1977. Dysphagia and esophageal diverticula. Postgraduate Medicine, 61, 155-161. KAYE, M. D., 1974. Oesophageal motor dysfunction in patients with diverticula of the mid-thoracic oesophagus. Thorax, 29, 666-672. MESHKINPOUR, H., 1985. Esophageal diverticula. In Bockus Gastroenterology, 4th edn, Vol. 2, ed. by J. Edward Berk (W. B. Saunders Company, Philadelphia, USA), pp. 809-817.
The use of combined transoesophageal echocardiography and fluroscopy in the biopsy of a right atrial mass By P. J. Scott, MRCP, D. F. Ettles, MRCP, M. R. Rees, MRCP, FRCR and G. J. Williams, FRCP, FACC Non-Invasive Cardiac Unit and X-Ray Department, Killingbeck Hospital, York Road, Leeds {Received July 1989)
Transoesophageal echocardiography has increasing Case report A 14-year-old Asian boy presented with a short history of application to the diagnosis of a wide range of cardiac disorders (Roelandt & Sutherland, 1988). Recently, malaise, cough and haemoptysis associated with intermittent simultaneous ultrasound imaging of the heart by the pleuritic chest pain. Physical examination revealed signs of bilateral pleural effusions and right-sided heart failure, with oesophageal route has been used during certain inter- jugular venous pressure elevated 6 cm above the suprasternal ventional cardiac procedures (Cryan et al, 1988; notch and mild peripheral oedema. His pulse rate was 90 beats/ Neumann et al, 1988). min and his blood pressure was 140/80 mmHg with no paraWe report a case in which transoesophageal echocar- dox. The pleural effusions were confirmed radiologically, but diography was used in combination with fluroscopy to the chest radiograph and electrocardiogram (ECG) yielded no further diagnostic information. Pulmonary infarcts were facilitate the biopsy of a right atrial mass. Address for correspondence: Dr Peter J. Scott, Non-Invasive Cardiac Unit, Killingbeck Hospital, York Road, Leeds LS14 6UQ. 222
suspected and, in the search for a source of emboli, praecordial cardiac ultrasound revealed distortion of the tricuspid valve annulus. This was further delineated by transoesophageal echocardiography which clearly showed a mass in the posterolateral
Vol. 63, No. 747
Case reports Giant mid-oesophageal diverticulum: a rare cause of dysphagia By R. J . Etherington, FRCR and *D. Clements, MRCP Departments of Diagnostic Radiology and *Gastroenterology, University Hospital of Wales, Heath Park, Cardiff CF44XW
(Received March 1989 and in revised form September 1989)
Mid-oesophageal diverticula are usually small, asymptomatic and rarely result in complications (Meshkinpour, 1985). We report a case of a giant mid-oesophageal diverticulum which caused dysphagia. The aetiology of these diverticula is discussed. Case report A 91-year-old man presented with a long history of dysphagia and weight loss of over 20 kg. More recently he had developed vomiting and symptoms of nocturnal aspiration. The dysphagia had become severe and he required intravenous fluids to maintain his hydration. The chest radiograph demonstrated an irregular gas lucency inferior to the carina (Fig. 1). There was no evidence of previous tuberculous infection. Barium swallow examination revealed a huge sac arising from the mid-part of the oesophagus and extending to the left and anterior to it. Initially, the sac appeared thick walled (Fig. 2), but on delayed radiographs barium penetrated the food residue within it revealing a thin walled diverticulum. Barium preferentially entered the diverticulum, then overflowed into the distal oesophagus which was Address correspondence to: Dr R. J. Etherington, Senior Registrar, Department of Diagnostic Radiology, University Hospital of Wales, Heath Park, Cardiff CF4 4XW.
Figure 2. Early lateral film from barium swallow showing contrast medium entering the diverticulum. displaced by the diverticulum and demonstrated non-propulsive contractions. Endoscopy confirmed the radiological findings of a large mid-oesophageal diverticulum. The distal oesophagus was macroscopically normal and the endoscope passed readily into the stomach. He was not willing to undergo oesophageal manometry. Surgery was also refused so he was fed enterally via a nasogastric tube.
Discussion Figure 1. Chest radiograph demonstrating an irregular gas lucency in the mediastinum (arrows).
The British Journal of Radiology, March 1990
Oesophageal diverticula may be classified anatomically as pharyngo-oesophageal, mid-oesophageal, intramural and epiphrenic. Classification into traction and pulsion on the basis of the presumed aetiology was first 221
Case report
1990, The British Journal of Radiology, 63, 222-224
suggested by Rokitansky in 1840 (from Meshkinpour, 1985). Mid-oesophageal diverticula are widely thought to be of traction origin; this is based on early observations of an association between tuberculous lymph nodes and diverticula of the adjacent oesophagus. Although diverticula are associated with other causes of mediastinal fibrosis such as treated non-Hodgkin's lymphoma (Barosi et al, 1976) and histoplasmosis (Jenkins et al, 1976), post-mortem studies have failed to demonstrate fibrous adhesions in most cases suggesting that traction is the cause in only a minority. It has also been suggested that oesophageal motility disorders may result in mid-oesophageal diverticula. Kaye (1974) found manometric evidence of significant oesophageal motor dysfunction in 10 out of 12 patients. Similarly, Borrie and Wilson (1980) found motor abnormalities in four of five cases. Other potential explanations include a congenital origin (Borrie & Wilson, 1980) or pseudo-diverticulum due to a walled-off perforation. Mid-oesophageal diverticula are rarely symptomatic (Jordan, 1977; Meshkinpour, 1985) since they are generally small, have wide necks and the sac is usually higher than the neck of the diverticulum, preventing the retention of food (Meshkinpour, 1985). Our case is unusual because the diverticulum was symptomatic. This may be partly a result of its large size causing oesophageal displacement. In addition, the position of the sac predominantly below the level of its neck resulted in preferential filling of the diverticulum.
The aetiology of this diverticulum is unclear; although formal manometric studies could not be performed the uncoordinated distal oesophageal contractions did not delay the passage of barium, so they may be clinically insignificant. There was no evidence of previous tuberculosis and no history to suggest previous oesophageal perforation. A mid-oesophageal diverticulum should be considered in the differential diagnosis of dysphagia, and as a cause of an abnormal gas collection in the middle mediastinum on plain radiographs. Barium swallow readily confirms the diagnosis. References BAROSI, G., MORANDI, S. & ASCARI, E., 1976. On a case of
esophagus Remission 219-223.
involvement by non-Hodgkin's lymphoma. by chemotherapy alone. Hematologica, 61,
BORRIE, J. & WILSON R. L. K., 1980. Oesophageal diverticula:
principles of management and appraisal of classification. Thorax, 35, 759-767. JENKINS, D. W., FISK, D. E. & BYRD, R. B., 1976. Mediastinal
histoplasmosis with esophageal abscess. Gastroenterology, 70, 109-111. JORDAN, P. H., 1977. Dysphagia and esophageal diverticula. Postgraduate Medicine, 61, 155-161. KAYE, M. D., 1974. Oesophageal motor dysfunction in patients with diverticula of the mid-thoracic oesophagus. Thorax, 29, 666-672. MESHKINPOUR, H., 1985. Esophageal diverticula. In Bockus Gastroenterology, 4th edn, Vol. 2, ed. by J. Edward Berk (W. B. Saunders Company, Philadelphia, USA), pp. 809-817.
The use of combined transoesophageal echocardiography and fluroscopy in the biopsy of a right atrial mass By P. J. Scott, MRCP, D. F. Ettles, MRCP, M. R. Rees, MRCP, FRCR and G. J. Williams, FRCP, FACC Non-Invasive Cardiac Unit and X-Ray Department, Killingbeck Hospital, York Road, Leeds {Received July 1989)
Transoesophageal echocardiography has increasing Case report A 14-year-old Asian boy presented with a short history of application to the diagnosis of a wide range of cardiac disorders (Roelandt & Sutherland, 1988). Recently, malaise, cough and haemoptysis associated with intermittent simultaneous ultrasound imaging of the heart by the pleuritic chest pain. Physical examination revealed signs of bilateral pleural effusions and right-sided heart failure, with oesophageal route has been used during certain inter- jugular venous pressure elevated 6 cm above the suprasternal ventional cardiac procedures (Cryan et al, 1988; notch and mild peripheral oedema. His pulse rate was 90 beats/ Neumann et al, 1988). min and his blood pressure was 140/80 mmHg with no paraWe report a case in which transoesophageal echocar- dox. The pleural effusions were confirmed radiologically, but diography was used in combination with fluroscopy to the chest radiograph and electrocardiogram (ECG) yielded no further diagnostic information. Pulmonary infarcts were facilitate the biopsy of a right atrial mass. Address for correspondence: Dr Peter J. Scott, Non-Invasive Cardiac Unit, Killingbeck Hospital, York Road, Leeds LS14 6UQ. 222
suspected and, in the search for a source of emboli, praecordial cardiac ultrasound revealed distortion of the tricuspid valve annulus. This was further delineated by transoesophageal echocardiography which clearly showed a mass in the posterolateral
Vol. 63, No. 747
