A 68-year-old man reports progressive dysphagia, regurgitation of undigested food eaten many hours earlier, loud gurgling noises on swallowing, and nocturnal cough with aspiration. Barium swallow shows a contrast-filled sac in the upper oesophagus deviating to the left. Which defect underlies this condition?

• A Failure of relaxation of the lower oesophageal sphincter
• B Weakening of the diaphragmatic hiatus with gastric prolapse
• C Traction pull from mediastinal lymph node adhesions
• D Herniation through Killian's dehiscence between the thyropharyngeus and cricopharyngeus ✓

Explanation

This is a pharyngeal pouch (Zenker diverticulum), a pulsion diverticulum caused by neuromuscular incoordination of the cricopharyngeus, forcing mucosa through Killian's dehiscence, the weak area between the oblique fibres of thyropharyngeus and the transverse fibres of cricopharyngeus. Regurgitation of old food, gurgling and nocturnal aspiration are typical. Achalasia involves the lower sphincter, traction diverticula arise in the mid-oesophagus from adhesions, and hiatus hernia produces reflux rather than retained food.

Reference: Bailey and Love's Short Practice of Surgery, 28th ed.

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Written and medically reviewed by the StethoPrep medical team.