A 57-year-old man presents to the physician for halitosis, regurgitation of undigested food, progressive difficulty swallowing, and an occasional gurgling noise in the throat for the past 4 months. He has not experienced odynophagia, nausea, vomiting, heartburn, or weight loss. He has a history of gastroesophageal reflux disease which is well-controlled with proton pump inhibitor, and he was evaluated with an endoscopy which was unremarkable two years ago.
Which of the following is the next best step in the evaluation of this patient?
- A) Ambulatory esophageal pH monitoring
- B) Barium esophagography
- C) Esophageal manometry
- D) No diagnostic testing necessary
- E) Repeat upper endoscopy
B) Barium esophagography
The patient most likely has pharyngoesophageal diverticulum, also known as Zenker diverticulum. It is typically seen in middle-aged men and is acquired likely due to structural weakness of a portion of a triangular area in the wall of the pharynx between the cricopharyngeus and thyropharyngeus. This type of diverticulum is typically asymptomatic but can also present with dysphagia, regurgitation of undigested food, noisy swallowing, halitosis, cough, reflux symptoms, and weight loss. It can be visualized on barium esophagography.
Answer choice A: Ambulatory esophageal pH monitoring, is incorrect. Ambulatory esophageal pH monitoring is used to confirm and quantify acid exposure in the esophagus and used in the evaluation of refractory GERD.
Answer choice C: Esophageal manometry, is incorrect. Esophageal manometry can evaluate motility disorders such as achalasia. It can be considered in this case only if barium esophagography and endoscopy are unrevealing.
Answer choice D: No diagnostic testing necessary, is incorrect. This patient’s presentation warrants further work up.
Answer choice E: Repeat upper endoscopy, is incorrect. Upper endoscopy can diagnose a Zenker diverticulum through direct visualization; however, it is not the first diagnostic test to be performed, especially given the risk of perforation during the procedure.
Key Learning Point
The best initial diagnostic test for pharyngoesophageal diverticulum is barium esophagography.
Dr. Raj Dasgupta