P0512 - A Rare Case of a Zenker's Diverticulum

Akil Olliverrie, MBBS¹, Joshua Diaz, MD¹, Sara Samad, DO², Abdullah Muhammad, MD^1
1South Brooklyn Health, Brooklyn, NY; ²NYC Health + Hospitals, South Brooklyn Health, Brooklyn, NY

Introduction: A Zenker's Diverticulum (ZD) is a sac-like outpouching of the mucosa and submucosa through Killian's triangle, an area of muscular weakness between the transverse fibers of the cricopharyngeus muscle and the oblique fibers of the lower inferior constrictor muscle. The reported prevalence of ZD is between 0.01 and 0.11 percent. The diagnosis of ZD is made on Barium swallow examination however an endoscopy is recommended to exclude a concurrent malignancy. This case highlights the incidental finding of a Zenker’s Diverticulum on an emergent endoscopy.

Case Description/Methods: This medical encounter describes an 81 year old female with an extensive medical history, most notably are CHF , Mobitz type 2, HTN, Anemia and recurrent lower extremity DVT on Apixaban who presented to our ED in Grade 3 Haemorrhagic shock, with an Hgb of 4 on istat blood works. Visible bouts of coffee ground and melanotic stool were witnessed by care providers. Massive Transfusion protocol was initiated and prothrombin complex ordered for reversal of Apixaban.

Resuscitative measures were successful (total of 9 units of Blood transfused), patient was intubated for airway protection, admitted to the MICU and stat GI consult placed for endoscopy evaluation and management.

Endoscopic evaluation revealed Grade C oesophagitis and Forrest Class IIb gastric ulcer (clips placed).

Incidentally, a Zenker’s Diverticulum with apparent perforation by an OGT placed during resuscitation (OGT removed prior to EGD) with fresh edges was noted and repaired with two hemostatic clips.

Discussion: Our case features a rare occurrence of a Zenker’s Diverticulum. With a prevalence of just 0.01 to 0.11 it is worth mentioning these infrequent sightings as many physicians may only have read about such conditions in their career. The unfortunate turn of events (perforation with an OGT) that ultimately lead to the diagnosis just adds to the sparsity of these conditions being diagnosed. Endoscopy is usually not indicated for diagnosis as it has a low sensitivity, thus small outpouchings can be easily missed. Instrumentation of the oesophagus should generally be avoided or performed only if absolutely indicated and under extreme caution as the risk of perforation is increased as seen in this case. Intervention is usually reserved for symptomatic or large diverticulums.



Disclosures:


Akil Olliverrie, MBBS¹, Joshua Diaz, MD¹, Sara Samad, DO², Abdullah Muhammad, MD¹. P0512 - A Rare Case of a Zenker's Diverticulum, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.