Gullet diverticulum — the protrusion of a wall of a gullet which is reported with its gleam. Diverticulums happen true (containing all layers of an esophageal wall) and false (protrusion of a mucous membrane through defect of a muscular layer).
Epidemiology Diverticulums of a gullet occur rather often, Approximately at 1,5% of persons, is more often at advanced age and at the patients having other diseases of system of digestion (cholecystitis, cholelithiasis, a peptic ulcer of a stomach and duodenum, etc.). Diverticulums of a gullet can develop in any its site, but bifurcation meet more often, is more rare — pharyngoesophageal and epifrenalny (epiphrenic).
Etiology and pathogeny In an origin of diverticulums of a gullet matter: a) the inborn or acquired weakness of a muscular coat in a certain site of an esophageal wall; b) disturbance of an esophageal vermicular movement and emergence of the spastic reductions causing protrusion of a wall of a gullet in the weakest place or places (so-called pressure diverticulums); c) existence of connective tissue unions of a wall of a gullet, is more often with lymph nodes of a mediastinum, for example at their tubercular defeat (traction diverticulums). In many cases these mechanisms operate at the same time, i.e. by origin these diverticulums are mixed.
Classification Inborn and acquired allocate diverticulums; the last are subdivided on pulsion, traction and mixed. In the diagnosis specify localization, the sizes, a diverticulum form, its oporozhnyaemost (good, without residual contents, moderate, bad — with a considerable and long delay in a diverticulum of a contrast agent). Specify also existence or lack of a diverticulitis.
Approximate formulation of the diagnosis: The acquired pressure diverticulum of a gullet; esophagism; calculous cholecystitis.
Clinical picture, preliminary diagnosis At most of patients, especially with small diverticulums, resistant symptoms of a disease can be absent. Only incidentally there is a dysphagy, is more often at hasty food, food with no drink. At diverticulums of the big sizes the dysphagy arises almost at each meal, in a prone position regurgitation (the return flowing) of diverticulum contents in a gullet and a throat, vomiting can be observed. These patients can note an unpleasant smell (owing to decomposition of the food remains which were late in a gullet). Major importance for diagnosis of a diverticulum has contrast X-ray inspection at which establish a diverticulum, determine its sizes, a form, existence or absence in it the contrast weight and the food remains. Small diverticulums of an average and lower third of a gullet in which contrast weight is not late come to light at X-ray inspection of a gullet in position of the patient lying better. The proceeding diverticulums small asymptomatically often are an accidental radiological find at the contrast X-ray inspection conducted in other occasion. The diverticulums connecting to a gullet the wide message reveal at an ezofagoskopiya. Over time diverticulums quite often increase in sizes. At bad emptying of a diverticulum (at a meshkoobrazny form, with the bottom located diverticulum necks are much lower) in it the food (especially badly chewed pieces) which can decay is late; danger of emergence of a diverticulitis is big, and then — a mediastinitis. In a diverticulitis also the swallowed foreign bodys can be late (pieces of a chicken or fish bone, etc.).
Differential diagnosis, verification of the diagnosis Usually radiological data are so convincing that need for confirmatory and differential diagnosis does not arise. Differentiation with rare anomaly — partial doubling of a gullet in the presence of the message between an additional cavity and the main gleam of a gullet is only in some cases necessary. Sometimes it is possible to take the formed fistular course in a mediastinum or a trachea at local suppuration for a diverticulum (abscess) of an esophageal wall at an injury (for example, a chicken or fish bone) or at disintegration of a tumor of an esophageal wall. However in these cases usually are available a severe retrosternal pain when swallowing, the general signs of an inflammation (fever, a leukocytosis, increase of SOE) or tumoral process (loss of appetite" weight loss etc.). Ezofagoskopiya (sometimes with an aim biopsy) allows to specify the diagnosis.
Treatment In the absence of indications to surgical treatment (or at serious contraindications to it) therapy is directed to prevention of a delay in a diverticulum of food masses and developments of a diverticulitis. The patient is recommended to eat well crushed food, to carefully chew it; after meal it is necessary to take several sips of water or unsweetened tea "to wash out" a diverticulum. With diverticulums of the big sizes and at a delay of food in them during after-dinner rest or before a night dream it is desirable for patient to adopt in the beginning such provision which promotes emptying of a diverticular bag. Surgical treatment is shown at diverticulums of the big sizes, at diverticulums in which owing to features of their form (a bottom down) and to the narrow message (neck) with a gullet gleam the long time is late food, at development of a diverticulitis.