A 35-year-old woman reported feeling pressure in her lower neck and chest a few hours after meals. The symptoms had started several months prior. The sensation was worse with dry foods, such as bread. She had a history of chronic idiopathic urticaria, which was well controlled with cetirizine. She was not allergic to any medications.

Although the patient did not report weight loss, she had lost 3% of her body weight on chart review. Physical examination did not reveal oropharyngeal or abdominal abnormalities. A barium swallow test was ordered (Figure 1).

QUESTION

Based on the patient’s history and physical examination, which one of the following is the most likely diagnosis?

• A. Eosinophilic esophagitis.

• B. Esophageal cancer.

• C. Esophageal stricture.

• D. Esophageal webs.

• E. Zenker diverticulum.

DISCUSSION

The answer is E: Zenker diverticulum, an outpouching of esophageal mucosa and submucosa through the posterior esophageal wall between the thyropharyngeus and cricopharyngeus muscles. The condition is thought to be caused by increased hypopharyngeal pressure secondary to incomplete opening of the upper esophageal sphincter. Zenker diverticulum is most common in men 70 to 80 years of age. It presents with dysphagia, regurgitation of undigested foods, and halitosis. When untreated, the most common complications include chronic cough, aspiration, and weight loss.