Diagnosis is often incidental to examination of the gastrointestinal tract for other conditions, because traction diverticula usually cause no symptoms. Unless a very large esophagoscope be used, a traction diverticulum may easily be overlooked in the mucosal folds. Careful lateral search, however, will reveal the dilatation, and the localized periesophageal fixation may be demonstrated. The subdiverticular esophagus is readily followed, its lumen opening during inspiration unless very close to the diaphragm, which is very rare. Perhaps most cases will be discovered by the roentgenologist. It has been said that traction diverticula are more readily demonstrated in the roentgenologic examination, if the patient be placed with pelvis elevated.
Pulsion diverticulum of the esophagus is an acquired hernia of the mucosa between the circular and oblique fibers of the inferior constrictor muscle of the pharynx. A congenital anatomic basic factor in etiology probably exists. The pouching develops in the middle part of the posterior wall, between the orbicular and oblique fibers of the cricopharyngeus muscle, at which point there is a gap, leaving the mucosa supported only by a not very resistant fascia (Fig. 100). When small, the sac is in the midline, but with increase in size, it presents either to the right or the left side, commonly the latter. The sac may be very small, or it may be sufficiently large to hold a pint or more, and to cause the neck to bulge when filled. When large, the pouch extends into the mediastinum. It will be seen that anatomically the pulsion diverticulum has its origin in the pharynx; the symptoms, however, are referable to the esophagus and the subdiverticular esophagus is stenosed by compression of the pouch; therefore, it is properly classified as an esophageal disease.
[FIG. 100.—Schema illustrative of the etiology of pressure diverticula. O, oblique fibers of the cricopharyngeus attached to the thyroid cartilage, T. The fundiform fibers, F, encircle the mouth of the esophagus. Between the two sets of fibers is a gap in the support of the esophageal wall, through which the wall herniates owing to the pressure of food propelled by the oblique fibers, O, advance of the bolus being resisted by spasmodic contraction of the orbicular fibers, F.]
Etiology.—Pressure diverticula occur after middle life, and more often in men than in women. The hasty swallowing of unmasticated food, too large a bolus, defective or artificial teeth, flaccidity of tissues, and spasm of the cricopharyngeus muscle, are etiologic factors. Cicatricial stenosis below the level of the inferior constrictor is a contributory cause in some cases.
Prognosis.—After the pouch is formed, it steadily increases in size, since the swallowed food first fills and distends the sac before the overflow passes down the esophagus. When a pendulous sac becomes filled with food, it presses on the subdiverticular esophagus, and produces compression stenosis; so that there exists a "vicious circle." The enlargement of the sac produces increasing stenosis with consequent further distension of the pouch. This explains the clinically observed fact, that unless treated, pulsion diverticula increase progressively in size, and consequently in distressing symptoms. The sac becomes so large in some cases as to contribute to the occurrence of cerebral apoplexy by interference with venous return. Practically all cases can be cured by radical operation. The operative mortality varies with the age, state of nutrition, and general health of the patient. In general it may be said to have a mortality of at least 10 per cent, largely due to the fact that most cases are poor surgical subjects. Recurrences after radical operation are due to a persistence of the original causes, i.e., bolting of food; stenosis, spasmodic or organic, of the esophageal lumen; and weakness in the support of the esophageal wall, which, unsupported, has little strength of its own.
Symptoms.—Dysphagia, regurgitation, a gurgling sound and subjective bubbling sensation on swallowing, sour odor to the breath, and cough, are the chief symptoms. With larger pouches, emaciation, pressure sensation in the neck and upper mediastinum, and the presence of a mass in the neck when the sac is filled, are present. Tracheal compression by the filled pouch may produce dyspnea. The sac may be emptied by pressure on the neck, this means of relief being often discovered by the patient. The sac sometimes spontaneously empties itself by contraction of its enveloping muscular layer, and one of the most annoying symptoms is the paroxysm of coughing, waking the patient, when during the relaxation of sleep the sac empties itself into the pharynx and some of its contents are aspirated into the larynx. There are no pathognomonic symptoms. Those recited are common to other forms of esophageal stenosis, and are urgent indications for diagnostic esophagoscopy.
Diagnosis.—Roentgenray study with barium mixtures, is the first step in the diagnosis (Fig. 101). This is to be followed by diagnostic esophagoscopy. Malignant, spasmodic, cicatricial, and compression stenosis are to be excluded by esophagoscopic appearances. Aneurysm is to be eliminated by the usual means. The Boyce sign is almost invariably present, and is diagnostic. It is elicited by telling the patient to swallow, which action imprisons air in the sac. The imprisoned air is forced out by finger-pressure on the neck, over the sac. The exit of the air bubble produces a gurgling sound audible at the open mouth of the patient.
Esophagoscopic Appearances in Pulsion Diverticulum.—The esophagoscope will without difficulty enter the mouth of the sac which is really the whole bottom of the pharynx, and will be arrested by the blind end of the pouch, the depth of which may be from 4 to 10 cm. In some cases the bottom of the pouch is in the mediastinum. The walls are often pasty, and may be eroded, or ulcerated, and they may show vessels or cicatrices. On withdrawing the tube and searching the anterior wall, the subdiverticular slit-like opening of the esophagus will be found, though perhaps not always easily. The esophageal speculum will be found particularly useful in exposing the subdiverticular orifice, and through this a small esophagoscope may be passed into the esophagus, thus completing the diagnosis. Care must be exercised not to perforate the bottom of the diverticular pouch by pressure with the esophagoscope or esophageal speculum. The walls of the sac are surprisingly thin.
[FIG. 101.—Pulsion diverticulum filled with bismuth mixture in a man of fifty years.]
Treatment of Pulsion Diverticulum.—If the pouch is small, the subdiverticular esophageal orifice may be dilated with esophagoscopic bougies, thus overcoming the etiologic factor of spastic or organic stenosis. The redundancy remains, however, though the symptoms may be relieved. Cutting the common wall between the esophagus and the sac by means of scissors passed through the endoscopic tube, has been successfully done by Mosher.