Medical Mystery: What caused old man’s swallowing trouble?

An 84-year-old patient came to see me with a serious problem: He had a terrible time swallowing his food, and when he did manage the task, it generally came right back up again.

Ten years ago, he had undergone a barium swallow — an X-ray imaging test used to visualize the structure of the esophagus — and was told he had a small diverticulum, an abnormal sac or pouch formed at a weak point in the wall of the gastrointestinal tract.

There are multiple types of diverticula that can occur in the upper esophagus. Regardless of the type of diverticulum, many patients complain of difficulty swallowing, bad breath, and regurgitating food after eating. If the symptoms get severe enough, some patients may suffer from weight loss or aspiration, leading to pneumonia.

When the man's symptoms began a decade ago, they were mild. He modified his diet, which proved successful for a while. But eventually the symptoms progressed.

Over time, the diverticulum began collecting the majority of the food he was eating and even medication he needed to take, resulting in a 15-pound weight loss.

His tipping point came on Father's Day last year while out with his family at a restaurant. He could barely eat anything. When he went outside to get a breath of fresh air, he threw up.

He wondered, "Was there anything  that could be done to help me?"

The patient's primary-care doctor referred him to me. I obtained a repeat barium swallow, which confirmed the diagnosis of a Killian-Jamieson diverticulum.

However, compared with his original study, the diverticulum had significantly increased in size, almost entirely obstructing his throat.

This time, I was able to offer the man a variety of treatment options, including surgical interventions.

Many upper esophageal diverticula can be treated endoscopically, through the mouth, with no incisions in the neck. This is most commonly performed for Zenker's diverticulum, another type of upper esophageal diverticulum, similar to the patient's condition.

Alternatively, upper esophageal diverticula can be treated through an open surgical approach, where an incision is made in the neck and the pouch is removed.

After reviewing all the information, he wanted to try to treat his diverticulum endoscopically, if we were able. We would be able to make this assessment only at the time of surgery.

After the patient was under anesthesia, an upper endoscopy was performed to evaluate the esophagus and stomach. We were able to identify the diverticulum, projecting from the left side of the upper esophagus. We used a special scope to better visualize the diverticulum and a surgical stapling device to remove it.  After surgery, we kept him in the hospital overnight and discharged him the following day.

The patient's recovery went very well, and within a month, he was advancing his diet and able to eat solid foods. After almost a decade of a modified diet, I asked him what the first thing he was going to eat again was. His choice: a nice, juicy hamburger.

Colin Huntley, MD is an otolaryngologist and assistant professor of otolaryngology-head and neck surgery at Sidney Kimmel Medical College at Thomas Jefferson University.