Case Report

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Massive upper GI bleeding: A rare complication

of Zenkers diverticulum
Haas I, Gutman M, Paran H

Department of Surgery
A, Meir Medical Center,
Kfar Sava, affiliated to the
faculty of Medicine,
Tel-Aviv University, Israel
Correspondence:
Haim Paran
E-mail: paranh@clalit.org.il
Received
: 26-02-08
Review completed : 27-03-08
Accepted
: 31-03-08
pubMed ID
: 18626170
J Postgrad Med 2008;54:209-10

ABSTRACT
Bleeding from a Zenkers diverticulum is rare. A 71-year-old man was urgently admitted with massive
hematemesis. It was known that he had a Zenkers diverticulum, but on emergency endoscopy, the source of
bleeding was not detected due to large blood clots in the esophagus, hypo-pharynx and also into the trachealbronchial tree. Computerized tomography angiography demonstrated a blush of intravenous contrast arising
from the diverticulum. The patient was operated upon urgently; the diverticle had a deep ulceration which
was the source of the bleeding. The cause of the ulceration is unknown but it is possible that it was caused
by the direct effect of an aspirin pill within the diverticle. A similar case with the same conclusion has been
published in the past and since the use of aspirin has become common, especially in the elder population,
we present this case report to highlight this possible life-threatening complication of Zenkers diverticulum in
patients receiving aspirin.
KEY WORDS:
WORDS Aspirin, bleeding, mucosal ulceration, Zenkers diverticulum

leeding from a Zenkers diverticulum is rare and

since documented cases in the literature are very few,
no guidelines exist for the management of this potentially
life-threatening condition. The pathophysiology of the
ulceration is also unknown. We present a case of acute massive
bleeding in a patient with Zenkers diverticulum and discuss a
possible mechanism for this rare complication.
Case History
A 71-year-old man was urgently admitted to our department of
general surgery from the emergency room due to hematemesis.
His medical background showed that he suffered from
hypertension, ischemic heart disease, diabetes mellitus,
chronic obstructive pulmonary diseases and dyslipidemia.
His medication included aspirin. A few months before the
present admission, he underwent a left hemicolectomy due to
adenocarcinoma of the left colon, T2N1M0. After the operation
he was treated with chemotherapy with 5FU, leucoverin and
oxaliplatinum. At the present admission he was still receiving
chemotherapy. It was known that he had a Zenkers diverticulum
that caused regurgitation but the operation was postponed due
to the chemotherapy.
At admission he was hemodynamically stable, but had recurrent
hematemesis. An urgent gastroscopy was performed but the
source of bleeding was not detected due to large blood clots
in the esophagus, hypo-pharynx and also into the trachealbronchial tree. The possibility that the source of bleeding
was the lungs could not be excluded so a CT angiography was
performed and a blush of intravenous contrast was detected
arising from the diverticulum which was prominent to the right
J Postgrad Med July 2008 Vol 54 Issue 3

side of the neck entering the upper mediastinum [Figure 1].

The patient was operated upon urgently. The neck was explored
through an incision along the medial border of the right
sternocleidomastoid muscle and the diverticle was dissected.
The diverticle had a deep ulceration which was the source of
the bleeding [Figure 2]. It was resected with a linear stapler
and a cricopharyngeous muscle myotomy was performed. The
postoperative course was uneventful with no further bleeding
and he was discharged on the third postoperative day.
Discussion
Pharyngeal pouches (Zenkers diverticulum) occur most

Figure 1: CT angiography showing a blush of IV contrast (arrow) arising

from the diverticulum which was prominent to the right side of the neck
entering the upper mediastinum
209 !

Haas, et al.: Massive bleeding form Zenkers diverticulum

diverticle is unknown. Diverticulitis due to stasis of food has

been proposed as the causing factor. A previous report suggested
that the ulceration could be caused by aspirin pills which
theoretically could enter the pouch and stay with continuous
contact with the mucosa. As in our case all the reported patients
had also received aspirin.[2-4] Aspirin usually causes mucosal
injury in the lower part of the upper gastrointestinal region
due to inhibition of prostaglandins, but also due to prolonged
contact of the acidic pill with the mucosa.[2] In the the present
case, no signs of diverticulitis were found during the operation or
in the histopathology of the specimen. However, a deep mucosal
ulceration was found, further supporting a possible mechanism
of direct damage of the mucosa by the acid effect of aspirin.

Figure 2: Zenkers diverticle with a deep ulceration which was the

source of the bleeding

commonly in elderly patients. The etiology is physiological due

to a structural abnormality of the cricopharyngeous muscle.
The typical symptoms are regurgitation, aspiration, chronic
cough and dysphagia with weight loss. As the pouch enlarges
the symptoms become more severe.[1] Bleeding from a Zenkers
diverticulum is exceedingly rare and only a few case reports
exist in the literature. In the present case a CT angiography
was diagnostic since it showed extravagation of intravenous
contrast media, while the gastroscopy could not demonstrate the
bleeding source since there were blood clots in the esophagus,
in the diverticulum and also in the tracheal-bronchial tree.
The etiology and pathophysiology of ulceration within the

210

As the use of aspirin has become common, especially in the

elder population, we present this case report to highlight this
possible life-threatening complication of Zenkers diverticulum
in patients receiving aspirin.
References
1.
2.
3.
4.

Siddiq MA, Sood S, Strachan D. Pharyngeal pouch (Zenkers

diverticulum). Postgrad Med J 2001;77:506-11 .
Kensing KP, White JG, Korompai F, Dyck WP. Massive Bleeding from
a Zenkers Diverticulum: Case report and review of the literature.
South Med J 1994;87:1003-4.
Hendren WG, Anderson T, Miller JI. Massive bleeding in a Zenkers
diverticulum. South Med J 1990;83:362.
Odemis B, Ataseven H, Basar O, Ertugrul I, Yksel O, Turhan N.
Ulcer in the basis of Zenkers diverticulum mimicking esophageal
malignancy. J Natl Med Assoc 2006;98:1177-80.
Source of Support: Nil, Conflict of Interest: Not declared.

J Postgrad Med July 2008 Vol 54 Issue 3