Subdiaphragmatic esophageal diverticulum

　　The etiology of this disease is not yet clear. Cobum (1971) believes it may be related to the inability of the distal esophageal sphincter (distal sphincter) to completely relax. Pathological examination found that the diverticulum is a true subdiaphragmatic esophageal diverticulum containing all layers of the esophagus. The diverticulum epithelium is stratified squamous epithelium, with several small ulcerative areas on the surface, which are recent bleeding sites. Lymph nodes or other adjacent structures that can be seen in patients with esophageal traction diverticula were not seen. Therefore, it is speculated that subdiaphragmatic esophageal diverticulum is a prolapsed diverticulum.

　　Due to the accumulation of food, the diverticulum will continue to enlarge and gradually descend, which is not conducive to the excretion of the contents in the diverticulum, causing the opening of the diverticulum to face the lower part of the pharynx. All the food swallowed first enters the diverticulum and then regurgitates. At this time, there is difficulty in swallowing, which becomes progressive, and some patients also have symptoms such as halitosis, nausea, and loss of appetite. Some may become malnourished and lose weight due to difficulty in eating. If the diverticulum gradually enlarges and the accumulation of food and secretions begins to increase, sometimes they will automatically regurgitate into the oral cavity, occasionally causing aspiration. The result of aspiration will lead to complications such as pneumonia, atelectasis, or lung abscess.

　　Patients with subdiaphragmatic esophageal diverticulum mainly complain of upper abdominal pain, which occurs after meals and weight loss. Occasionally, upper abdominal pain can be induced after vomiting undigested food. Patients with this disease may also experience severe pain under the sternum, sometimes radiating to the back. The pain under the sternum worsens after eating and can be relieved when lying on the back or in the right lateral position.

　　The etiology of subdiaphragmatic esophageal diverticulum is not yet clear. Cobum (1971) believes it may be related to the inability of the distal esophageal sphincter to completely relax. There is no effective preventive measure, and early detection and early diagnosis are the key to the prevention and treatment of the disease.

　　Experts such as Cobum believe that subphrenic esophageal diverticula and abnormal esophageal pressure curves are due to the inability of the distal esophageal sphincter to relax completely. The inspection methods are as follows:

　　1. Esophagoscopy: The mucosa at a distance of 48 cm from the incisor is normal, and no diverticulum is seen.

　　2. Gastroscopy: A diverticular orifice of about 1 cm in diameter was found about 2 cm from the proximal end of the cardia, and its mucosa is similar to that of the esophagus.

　　3. Esophageal manometry:It shows that there is a high-pressure area about 5 cm in size 50 cm from the incisor to the esophagus. When the patient performs repeated swallowing movements, it is confirmed that the esophageal muscle below the high-pressure area 2 cm away from the distal end (below the diverticulum) cannot relax completely, the entire lower esophagus pressure increases, and the amplitude reaches 60 mmHg. The lower esophageal muscle undergoes delayed contraction and simultaneous contraction with the swallowing movement.

　　4. Upper gastrointestinal barium meal examination: The pouch-like bulge in front of the cardia has a thin strip-like orifice connected to the esophagus, which changes in shape with the movement of the diaphragm. There is no obvious delay or slowing down in the passage of barium through the esophagus and into the gastric cavity.

　　Patients with this disease should eat more liquid foods such as millet congee, and eat more foods rich in vitamins such as kiwi and pitaya. Pay attention to a balanced diet, eat less and more meals. Pay attention to rest and do appropriate exercise. Avoid smoking, drinking, and spicy and other刺激性 food.

　　The cases of subphrenic diverticula reported in the literature are extremely rare, so there is a need for more case reports and the accumulation of clinical experience for the clinical treatment of this disease. In these 2 patients, 1 case improved its clinical symptoms after conservative treatment by internal medicine, and after 1 year of follow-up, the patient's general health was good. The other case was cured by surgical resection of the diverticulum. Once the subphrenic esophageal diverticulum is diagnosed, it is best to undergo surgical treatment as long as the patient has no contraindications to surgery.