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Zenker's diverticulum | |
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Other names | Pharyngoesophageal diverticulum, pharyngeal pouch, hypopharyngeal diverticulum |
Specialty | Gastroenterology |
A Zenker's diverticulum, also pharyngeal pouch, is a diverticulum of the mucosa of the human pharynx, just above the cricopharyngeal muscle (i.e. above the upper sphincter of the esophagus). It is a pseudo diverticulum (not involving all layers of the esophageal wall).
It was named in 1877 after GermanpathologistFriedrich Albert von Zenker.[1][2]
Signs and symptoms[edit]
In simple words, when there is excessive pressure within the lower pharynx, the weakest portion of the pharyngeal wall balloons out, forming a diverticulum which may reach several centimetres in diameter.
More precisely, while traction and pulsion mechanisms have long been deemed the main factors promoting development of a Zenker's diverticulum, current consensus considers occlusive mechanisms to be most important: uncoordinated swallowing, impaired relaxation and spasm of the cricopharyngeus muscle lead to an increase in pressure within the distal pharynx, so that its wall herniates through the point of least resistance (known as Killian's triangle, located superior to the cricopharyngeus muscle and inferior to the thyropharyngeus muscle. Thyropharyngeus and cricopharyngeus are the superior and inferior parts of inferior constrictor muscle of pharynx respectively). The result is an outpouching of the posterior pharyngeal wall, just above the esophagus.[3]
While it may be asymptomatic, Zenker diverticulum can present with the following symptoms:
- Dysphagia (difficulty swallowing), and sense of a lump in the throat
- Food might get trapped in the outpouching, leading to:
- Regurgitation, reappearance of ingested food in the mouth
- Cough, due to food regurgitated into the airway
- Halitosis, smelly breath, as stagnant food is digested by microorganisms
- Infection
It rarely, if ever, causes any pain.
Cervical webs are seen associated in 50% of patients with this condition.
Rarer forms of cervical esophageal diverticula are the Killian's diverticulum and the Laimer's diverticulum. Killian's diverticulum is formed in the Killian-Jamiseon triangle (located inferior to the cricopharyngeus on both sides of this muscle's insertion into the cricoid cartilage). Laimer's diverticulum is formed in Laimer's triangle (located inferior to the cricopharyngeus in the posterior midline above the confluence of the longitudinal layer of esophageal muscle). Laimer's triangle is covered only by the circular layer of esophageal muscle.
Diagnosis[edit]
Lateral X-ray of a Zenker's diverticulum
AP X-ray of a Zenker's diverticulum
A combination of the simple barium swallow and a thorough endoscopy will normally confirm the diverticulum.[4]
Treatment[edit]
If small and asymptomatic, no treatment is necessary. Larger, symptomatic cases of Zenker's diverticulum have been traditionally treated by neck surgery to resect the diverticulum and incise the cricopharyngeus muscle. However, in recent times non-surgical endoscopic techniques have gained more importance (as they allow for much faster recovery), and the currently preferred treatment is endoscopic stapling[5][6] (i.e. diverticulotomy with staples ). This may be performed through a diverticuloscope. Other methods include fibreoptic diverticular repair.[7]
Other non-surgical treatment modalities also exist, such as endoscopic laser, which recent evidence suggests is less effective than stapling.[8]
Epidemiology[edit]
Zenker's diverticulum mainly affects older adults. It has an incidence of 2 per 100,000 per year in the UK, but there is significant geographical variation around the world.[9]
References[edit]
- ^synd/2461 at Who Named It?
- ^Zenker, FA; von Ziemssen, HW (1867). Krankheiten des Oesophagus. Leipzig: F.C.W. Vogel.
- ^van Overbeek, JJ (July 2003). 'Pathogenesis and methods of treatment of Zenkr's diverticulum'. Ann. Otol. Rhinol. Laryngol. 112 (7): 583–93. doi:10.1177/000348940311200703. PMID12903677.
- ^Bencini L, Moraldi L, Bartolini I, Coratti A (January 2016). 'Esophageal surgery in minimally invasive era'. World J Gastrointest Surg. 8 (1): 52–64. doi:10.4240/wjgs.v8.i1.52. PMC4724588. PMID26843913.
- ^Sen, P; Bhattacharyya, AK (August 2004). 'Endoscopic stapling of pharyngeal pouch'. J Laryngol Otol. 118 (8): 601–6. doi:10.1258/0022215041917817. PMID15453934.
- ^Chang, CY; Payyapilli, RJ; Scher, RL (June 2003). 'Endoscopic staple diverticulostomy for Zenker's diverticulum: review of literature and experience in 159 consecutive cases'. Laryngoscope. 113 (6): 957–65. doi:10.1097/00005537-200306000-00009. PMID12782805.
- ^Altman, JI; Genden, EM; Moche, J (May 2005). 'Fiberoptic endoscopic-assisted diverticulotomy: A novel technique for the management of Zenker's diverticulum'. Ann. Otol. Rhinol. Laryngol. 114 (5): 347–51. doi:10.1177/000348940511400503. PMID15966520.
- ^Miller, FR; Bartley, J; Otto, RA (September 2006). 'The endoscopic management of Zenker diverticulum: CO2 laser versus endoscopic stapling'. Laryngoscope. 116 (9): 1608–11. doi:10.1097/01.mlg.0000233508.06499.41. PMID16954989.
- ^Siddiq, MA; Sood, S; Strachan, D (August 2001). 'Pharyngeal pouch (Zenker's diverticulum)'. Postgraduate Medical Journal. 77 (910): 506–11. doi:10.1136/pmj.77.910.506. PMC1742115. PMID11470929.
External links[edit]
Classification |
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External resources |
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- Zenker's diverticulum at eMedicine
Retrieved from 'https://en.wikipedia.org/w/index.php?title=Zenker%27s_diverticulum&oldid=949787506'
Zenger, John PeterIn August of 1735 John Peter Zenger, a printer for the New York Weekly Journal, was prosecuted for seditious libel. Although Zenger may have been technically guilty of the crime as it was then defined by, a jury made up of twelve Americans acquitted the defendant in one of the earliest acts of colonial resistance to British authority during the eighteenth century.Zenger printed the allegedly seditious articles following a legal dispute between two public officials, William Cosby and Rip Van Dam.
![Zenger.com Zenger.com](https://www.zenger-neuhausen.de/files/zenger/media/bildergalerie/zenger_0032_zenger_au·en_002.jpg)
Cosby was appointed governor of New York in 1731, but did not officially take office until 1732. During the interim, Van Dam, the current governor, continued to discharge his official responsibilities, and collect a salary. Cosby, believing that he was entitled to the salary collected by Van Dam during this period, sued the lame duck governor for restitution. When the New York Supreme Court decided in favor of Van Dam, Cosby removed Chief Justice Lewis Morris and replaced him with James DeLancey, a judge who was friendlier to the new governor.On November 1, 1733, the first issue of the New York Weekly Journal appeared. The Journal was financially supported by Morris, edited by Van Dam's attorney, and printed by Zenger, a German immigrant with little education.
In a series of articles, the Journal accused Cosby of conspiring to persecute the inhabitants of New York and tainting their judicial system. Since Cosby had altered the composition of the state supreme court by replacing a political adversary with a political ally, the articles printed in the Journal possessed a kernel of truth.In January of 1734 Cosby attempted to imprison Zenger for seditious libel, but DeLancey failed to convince a to indict him. Ten months later a second grand jury declined to indict Zenger, prompting the governor's council to command the destruction of all offensive Journal articles.
When a third grand jury refused to issue an indictment against Zenger, Cosby ordered his attorney general to charge Zenger with seditious libel by 'information,' an alternative legal procedure by which criminal proceedings may be instituted against a defendant.The information accused Zenger of having printed several false, scandalous, and defamatory articles that tended to bring the governor into disrepute. The case was tried before the New York Supreme Court and Chief Justice DeLancey. Zenger's lawyers, Alexander and william smith, challenged the jurisdiction of the court to hear the dispute, and questioned DeLancey's impartiality. In response, DeLancey disbarred both attorneys. Subsequently, Andrew Hamilton, one of the most noted advocates in the colonies, agreed to represent Zenger for the trial's duration.The nub of Hamilton's defense rested upon the veracity of the articles printed in the Journal.
Acknowledging that truth was not a defense to seditious libel under the of England, Hamilton suggested that Americans enjoyed greater freedom than citizens of Great Britain, including the right to print truthful criticisms of the government and its officials. A published allegation of official misconduct, Hamilton argued, does not amount to libel unless proven false by the government.DeLancey instructed the jurors to consider only the factual question of whether Zenger had printed or published the articles in issue. The court said it would decide the legal question of whether they were libelous. However, Hamilton had earlier intimated that the jurors enjoyed the prerogative to ignore the judge's instructions, and render a verdict according to their collective conscience and the interests of justice. Contemporary observers reported that the jurors took only a 'small time' before returning a verdict of 'not guilty.' Zenger's trial served as a fountainhead for two different principles of American law. First, the Zenger trial represents the first case in America in which truth was asserted as a defense to an action for libel.
Although Americans were denied this defense under the common law of many jurisdictions during the two centuries that followed the Zenger trial, truth is now a constitutionally protected defense under the. In new york times co. Sullivan, 376 U.S. 2d 686 (1964), the U.S. Supreme Court cited the Zenger trial as one of the building blocks in this area of libel law.Second, the Zenger trial represents one of the first cases in which was exercised in America.
During the 1990s state and federal courts continue to recognize the right of juries to disregard the law and acquit certain defendants in order to prevent oppression by the government or to otherwise promote the interests of justice. This prerogative, which stems from the jury's role as the conscience of the community, is not formally acknowledged in a number of jurisdictions. However, in those jurisdictions that do recognize it, at least one court has pointed out that 'the roots of jury nullification in this country reach back to 1735 and the prosecution of Peter Zenger for seditious libel' U.S. Datcher, 830 F.Supp. Further readingsAlexander, James. A Brief Narrative of the Case and Trial of John Peter Zenger: Printer of the New York Weekly Journal. Birmingham, Ala.: Palladium.Glendon., William R.
'The Trial of John Peter Zenger.' New York State Bar Journal 68 (December).Putnam, William Lowell. John Peter Zenger and the Fundamental Freedom.
![John peter zenger facts John peter zenger facts](/uploads/1/2/5/3/125396846/703804908.jpg)
Jefferson, N.C.: McFarland. Cross-references;.Want to thank TFD for its existence?, add a link to this page, or visit.Link to this page: Zenger, John Peter.
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