Sellayah Renishka, Gurusinghe Nishanthi
Department of Surgery, Launceston General Hospital.
Department of Surgery, Launceston General Hospital.
Int J Surg Case Rep. 2024 Dec;125:110631. doi: 10.1016/j.ijscr.2024.110631. Epub 2024 Nov 23.
Bleeding from a Zenker's diverticulum is a rare occurrence, and currently no formal guidelines exist for its management. It is a potentially life-threatening condition and an important consideration in the differential diagnosis of haemoptysis or haematemesis.
A 63-year-old man presented with haemoptysis and haematemesis while on dual antiplatelet therapy for a recent NSTEMI. After resuscitation he underwent a CT angiogram which demonstrated an active contrast blush and pooling of contrast in a pharyngeal diverticulum. At endoscopy a large Zenker's diverticulum was encountered which contained an ulcerated area with general oozing of blood from multiple points and a single brisk bleeding point. Haemostasis was achieved with two syringes of a topical haemostatic agent.
Less than 15 case reports exist in the literature of this clinical entity, and fewer still have been managed successfully via endoscopic methods. The pathophysiology is unclear however may be related to antiplatelet agents exerting a topical effect after lodging in the diverticulum, causing ulceration, diverticulitis and bleeding. Early diagnosis can be challenging as patients may seem to present with haemoptysis, and delay to prompt diagnosis may further delay management.
This is the first Australian case report of bleeding from a Zenker's diverticulum who underwent successful endoscopic management. It highlights the diagnostic dilemma presented by this clinical entity and the subsequent impacts on management. Endoscopic haemostasis is an ideal intervention either as a definitive procedure in elderly patients unfit for surgery, or initial management as a bridge to surgery.
Zenker憩室出血是一种罕见的情况，目前尚无针对其治疗的正式指南。它是一种潜在的危及生命的病症，也是咯血或呕血鉴别诊断中的一个重要考虑因素。
一名63岁男性在因近期非ST段抬高型心肌梗死接受双联抗血小板治疗时出现咯血和呕血。复苏后，他接受了CT血管造影，显示咽部憩室有活动性造影剂外渗和造影剂聚集。在内镜检查中，发现一个大的Zenker憩室，其中有一个溃疡区域，多处有血液渗出，还有一个活跃的出血点。用两注射器局部止血剂实现了止血。
关于这一临床实体的文献报道少于15例，通过内镜方法成功治疗的更少。其病理生理学尚不清楚，但可能与抗血小板药物滞留在憩室中发挥局部作用，导致溃疡、憩室炎和出血有关。早期诊断可能具有挑战性，因为患者可能表现为咯血，而延迟到及时诊断可能会进一步延误治疗。
这是澳大利亚首例关于Zenker憩室出血并接受成功内镜治疗的病例报告。它突出了这一临床实体所带来的诊断困境以及对治疗的后续影响。内镜止血是一种理想的干预措施，对于不适合手术的老年患者可作为确定性手术，或作为手术桥梁的初始治疗。
