Clinical Pulmonary Medicine NetWork Puzzler - March 2011

Case Puzzler | 04.05.11

A Case of Recent Hemoptysis Postcardiac Surgery

Clinical Presentation
A 64 year-old man with a history of cardiac coronary bypass surgery 1 month ago has hemoptysis. His symptoms started 1 day prior, and he described these symptoms as bright red blood clots, brought up with cough, which was also recent. He complained of the sensation of a “lump in the throat,” which was sudden in onset. He was coughing up a clot every 1/2 to 1 h. He was taking daily aspirin, 325 mg; metoprolol; and amiodarone. The review of systems was remarkable only for dysphagia and mild pain at the thoracic incision site; the patient denied epistaxis, hematemesis, melena, nausea, vomiting, dizziness, syncope, shortness of breath, or orthopnea. He has never smoked and used to drink alcohol occasionally. He denied the use of any illicit drugs. His family history was significant for early coronary artery disease, as his father died of a myocardial infarction in his 50s.

On physical examination, the patient was not in any physical distress, and he was alert and oriented. His blood pressure was 150/87 mm Hg and pulse was 81/min. He was breathing at the rate of 18/min, with a hemoglobin oxygen saturation by pulse oximeter of 98% on room air. He was afebrile. On examination of his throat, there was no visible blood. Chest examination revealed a tender clean scar from his recent surgery and no associated abnormal breathing sounds. The rest of the physical examination results were normal.

Laboratory test results, including those for usual chemistries, thrombocytes, prothrombin time, international normalized ratio, and partial thromboplastin time, were unremarkable; RBC hemoglobin level was 11.3 g/dL. Chest radiograph did not show any abnormalities. A fiberoptic bronchoscopy on the second day of admission revealed a small amount of fresh blood above the vocal cords. Below the vocal cords, there was no source of bleeding identified.

Overnight, the patient coughed up copious amounts of blood clots. He was tachycardic and diaphoretic; his blood pressure was 102/56 mm Hg, and his pulse was 112/min. His hemoglobin level dropped to 9.6 g/dL, and he received a transfusion of 2 units of packed RBCs.

A barium transit series was obtained and is illustrated in Figure 1.

Figure 1. Barium transit study, upper esophageal phase.

Question: What is the diagnosis?

See the Answer

Answer: Zenker diverticulum, complicated by ulcer and significant mucosal hemorrhage

Clinical Course
The patient underwent a fiberoptic esophagoscopy, showing large-sized blood clots in the hypopharynx, which were removed with the endoscope. There was a large esophageal diverticulum emerging from the posterior wall of the proximal esophagus, which was filled with blood clots and obstructing the esophageal lumen distally. The esophagoscope could not be passed beyond the ostium of the diverticulum; hence, the procedure was terminated. A barium swallow study confirmed the presence of the large Zenker diverticulum. During each of the swallowing episodes, a moderate volume of the contrast bolus flowed into this diverticulum. There was no evidence of barium aspiration in the airways.

A cardiothoracic surgery consult was obtained for the excision of the diverticulum; due to its size and the hematologically and hemodynamically significant hemorrhage, the procedure was performed emergently. The excised diverticulum measured 3 x 1.5 x 2 cm and the histologic examination of the specimen revealed a centrally located ulcer in the diverticular mucosa, with focal areas of hyperemia and thickening (Fig 2). Postoperatively, no further bleeding episode was reported, and the patient was discharged home in stable condition.

Figure 2. Ulcerated Zenker diverticulum with acute and chronic inflammation (hematoxylin-eosin).

Discussion
Zenker diverticulum is an outpouching of the esophageal mucosa posteriorly, between the cricopharyngeus muscle and the inferior pharyngeal constrictor muscles. It is mainly seen in the elderly, and its prevalence in the United States is estimated to be between 0.01% and 0.11% of the population. A Zenker diverticulum carries with it a high frequency of retention of food elements within its pouch. Most commonly, Zenker diverticulum leads to the complaints of halitosis, regurgitation, aspiration, and dysphagia associated with weight loss. Bleeding in the diverticulum is exceedingly rare, and we have found only five cases reported in the medical literature. As in our case, all reported patients were taking daily aspirin.

The exact mechanism or mechanisms by which aspirin can cause mucosal ulceration or frank ulcer formation is not known. One postulated mechanism is that these acidic pills enter the diverticulum and stay with continuous contact with the mucosa, leading to a “pill-induced diverticulitis.” It is known to cause the inhibition of prostaglandin synthesis, which can account for the loss of local trophic factors. Diverticulitis, due to the stasis of food in the outpouch, is thought to be another possible mechanism, although the contribution of aspirin in this mechanism is unclear. In our case, we found no evidence of diverticulitis on the histopathology specimen.

An important aspect in the management of Zenker diverticulum is to keep in mind the risk of esophageal perforation when attempting esophageal instrumentation, such as side-viewing duodenoscope, nasogastric tube, and transesophageal echocardiogram. The endoscope should be withdrawn in the case of resistance during esophageal intubation.

Conclusions
In summary, the case presented here is of a patient with a relatively large Zenker diverticulum complicated by an ulcer and significant secondary hemorrhage. This type of presentation may pose diagnostic and therapeutic challenges to the clinician; hence, we think practitioners need to be aware of this condition.

Teaching Points

Zenker diverticulum can present as a rare cause of hemoptysis.
An ulcer in Zenker diverticulum resulting in a clinically significant bleed, in itself, is not very common.
Chronic use of aspirin is probably the most important factor in the ulcer formation.
Upper endoscopy, if attempted, to look for the cause of bleeding, should be performed very cautiously because of the risk of esophageal perforation. Barium swallow can be very helpful in the diagnosis.

Suggested Reading

Haas I, Gutman M, Paran H. Massive upper GI bleeding: a rare complication of Zenker’s diverticulum. J Postgrad Med. 2008;54(3):209-210.

Odemis B, Ataseven H, Basar O, Ertugrul I, Yukesl O, Turhan N. Ulcer in the basis of Zenker’s diverticulum mimicking esophageal malignancy. J Natl Med Assoc. 2006;98(7):1177-1180.

Kensing KP, White JG, Korompai F, Dyck WP. Massive bleeding from a Zenker’s diverticulum: case report and review of the literature. South Med J. 1994;87(10):1003-1004.

Hendren WG, Anderson T, Miller JI. Massive bleeding in a Zenker’s diverticulum. South Med J. 1990;83(3):362.

Shirazi KK, Daffner RH, Gaede JT. Ulcer occurring in Zenker’s diverticulum. Gastrointest Radiol. 1977;2(2):117-118.

Siddiq MA, Sood S, Strachan D. Pharyngeal pouch (Zenker’s diverticulum). Postgrad Med J. 2001;77(910):506-511.

Corresponding Author
Misbah Baqir, MD
602 Calibre Woods Dr NE
Atlanta, GA 30329
mbaqir@emory.edu
Phone: +01 (404) 512-9000
Fax: +01 (404) 417-1525

Co-Author
Octavian C. Ioachimescu, MD, PhD
oioachi@emory.edu
Phone: +01 (404) 321-6111 #2086
Fax: +01 (404) 417-1525

Affiliations
Emory University – Division of Pulmonary, Critical Care, Sleep Medicine
Atlanta VA Medical Center
Atlanta, Georgia

Case Puzzlers are a brief clinical vignette on various educational topics. Developed by members of the American College of Chest Physicians' NetWorks, it provides you an opportunity to sharpen your skills.

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Clinical Pulmonary Medicine NetWork Puzzler - March 2011

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