Esophageal Diverticulum

An esophageal diverticulum is an outpouching, or sac, that pushes out from the wall of the esophagus, the muscular tube that carries food from the throat to the stomach. When you swallow, some food and liquid can go into the pouch instead of passing down to the stomach. It may sit there for hours and then come back up.

Esophageal diverticula are uncommon. They're found in about 1–2% of patients evaluated for difficulty swallowing. Zenker's diverticulum accounts for roughly 70% of cases (Aiolfi et al., Surgical Endoscopy, 2026).

Doctors describe diverticula by where they occur and how they formed (Barry et al., The Esophagus, 2021).

By location:

• Upper (pharyngoesophageal) diverticula form where the throat joins the esophagus:
  • Zenker's diverticulum: the most common type. It bulges backward just above the upper esophageal sphincter (the cricopharyngeus muscle).
  • Killian-Jamieson diverticulum: a rarer pouch on the front side wall just below the cricopharyngeus. It's often mistaken for Zenker's, but it's treated differently (Antunes and Sloan, Current Gastroenterology Reports, 2023).
  • Laimer's diverticulum: extremely rare. It occurs at the back of the esophagus below the cricopharyngeus, usually in younger patients, and only a handful of cases have been reported (Antunes and Sloan, Current Gastroenterology Reports, 2023).

• Midesophageal diverticula form in the middle of the chest, near the windpipe's split into the lungs. They're also called parabronchial or traction diverticula, and they make up about 15% of esophageal diverticula (Li et al., BMC Gastroenterology, 2026).

• Epiphrenic diverticula form in the lowest 10 cm of the esophagus, just above the diaphragm (Holmes et al., Neurogastroenterology & Motility, 2020).

By how they formed:

• Pulsion ("false") diverticula are caused by high pressure inside the esophagus pushing the inner lining out through a weak spot in the muscle. Zenker's and epiphrenic diverticula are pulsion diverticula. Only the inner layers bulge out.

• Traction ("true") diverticula are caused by scarring outside the esophagus that pulls the wall outward. All layers of the wall are involved. Classic midesophageal diverticula are traction diverticula (Holmes et al., Neurogastroenterology & Motility, 2020).

The most important idea for patients: a diverticulum is often a sign of a deeper problem with how the esophagus squeezes and relaxes. Successful treatment almost always means fixing the pressure problem that created the pouch, not just removing the pouch itself.

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Each type of diverticulum has a different cause.

• Zenker's diverticulum: the upper esophageal sphincter (cricopharyngeus muscle) doesn't relax and open fully when you swallow. The muscle often becomes thick and bar-like. Every swallow raises the pressure above it, and over time the lining bulges out through a natural weak spot called Killian's triangle (Bhatt et al., JAMA Otolaryngology–Head & Neck Surgery, 2021). Acid reflux is strongly associated with Zenker's. Reflux reaching the upper sphincter may trigger forceful sphincter contraction, a cricopharyngeal bar, and in a minority of patients, a diverticulum (Aaron et al., American College of Surgeons Gastrointestinal Surgical Emergencies, 2021).

• Killian-Jamieson diverticulum: this pouch pushes through a separate weak area below the cricopharyngeus, close to the recurrent laryngeal nerve, which controls the vocal cord (Bock et al., Dysphagia, 2016).

• Midesophageal diverticula: these were historically traction diverticula caused by inflamed, scarred lymph nodes in the chest from tuberculosis, histoplasmosis, or sarcoidosis. Today, most midesophageal and epiphrenic diverticula occur together with an esophageal motility disorder and act like pulsion diverticula (Hirano, Yamada's Textbook of Gastroenterology, 2022).

• Epiphrenic diverticula: these are pulsion diverticula caused by high pressure in the lower esophagus. Usually the lower esophageal sphincter doesn't relax properly, or the esophageal muscle contracts in an uncoordinated or overly forceful way. About 75% of epiphrenic diverticula are associated with a motility disorder, such as achalasia or diffuse esophageal spasm (Holmes et al., Neurogastroenterology & Motility, 2020). Other associated disorders include esophagogastric junction outflow obstruction (EGJOO), jackhammer esophagus, and ineffective esophageal motility (Aiolfi et al., Surgical Endoscopy, 2026).

• Iatrogenic diverticula: in rare cases, a diverticulum can form after esophageal procedures, including endoscopic myotomy (POEM) (Sato et al., World Journal of Gastroenterology, 2019).

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• Older age: Zenker's diverticulum typically appears around age 70, and it's unusual before age 30 (Hirano, Yamada's Textbook of Gastroenterology, 2022).

• Male sex: Zenker's diverticulum is more common in men (Hirano, Yamada's Textbook of Gastroenterology, 2022).

• Esophageal motility disorders: achalasia, EGJOO, diffuse esophageal spasm, and hypercontractile (jackhammer) esophagus are the strongest risk factors for epiphrenic and midesophageal diverticula. About 5% of people with achalasia develop a diverticulum (Holmes et al., Neurogastroenterology & Motility, 2020).

• Cricopharyngeal dysfunction or a cricopharyngeal bar: this is the main risk factor for Zenker's.

• Gastroesophageal reflux disease (GERD): associated with Zenker's diverticulum (Aaron et al., American College of Surgeons, 2021).

• Past chest infections or inflammation: prior tuberculosis, histoplasmosis, sarcoidosis, or other conditions that scar the lymph nodes near the esophagus (Hirano, Yamada's Textbook of Gastroenterology, 2022).

• Prior esophageal surgery or endoscopic procedures (Sato et al., World Journal of Gastroenterology, 2019).

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A diverticulum works like a trap along your swallowing path. Food, pills, and saliva go into the pouch instead of passing to the stomach. That causes several problems:

• Food retention and regurgitation: food can sit in the pouch for hours, then come back up undigested, often when you bend over or lie down.

• Obstruction: a large pouch filled with food can press on the esophagus next to it and block swallowing almost completely. That can lead to significant weight loss (Yuan et al., Digestive Diseases and Sciences, 2024).

• Aspiration: contents from the pouch can spill into the windpipe, especially at night. This causes coughing, choking, hoarseness, and pneumonia. Hoarseness, cough, and aspiration pneumonia occur in 30–40% of patients with Zenker's diverticulum (Law et al., Clinical Gastroenterology and Hepatology, 2014).

• Medication problems: pills can lodge in the pouch. The medicine may then work less well, and the pill can cause ulceration and bleeding (Law et al., Clinical Gastroenterology and Hepatology, 2014).

• Chronic irritation of the lining: trapped food irritates the pouch lining for years. This is linked to a small but real cancer risk (Barry et al., The Esophagus, 2021).

In epiphrenic diverticula, the underlying motility disorder often causes symptoms of its own. Many patients have problems from both the pouch and the esophagus that isn't working properly.

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• Aspiration pneumonia and chronic lung infection: the most serious common complication. It can be life-threatening, especially in older adults (Yuan et al., Digestive Diseases and Sciences, 2024).

• Malnutrition and weight loss from progressive swallowing obstruction.

• Ulceration and bleeding in the pouch. Bleeding can sometimes be managed endoscopically (Barry et al., The Esophagus, 2021).

• Perforation: blindly passing a feeding tube, a breathing or nasogastric tube, an endoscope, or a heart ultrasound (TEE) probe can puncture a diverticulum (Hirano, Yamada's Textbook of Gastroenterology, 2022). Always tell your anesthesia team and other doctors that you have a diverticulum.

• Fistula: in rare cases, a midesophageal diverticulum can form an abnormal connection to the airway (bronchoesophageal fistula). This causes coughing when you drink liquids and repeated lung infections (Barry et al., The Esophagus, 2021).

• Cancer inside the diverticulum: this is rare. Squamous cell carcinoma has been reported in 0.3–7% of pharyngoesophageal (Zenker's), 1.8% of midesophageal, and 0.6% of epiphrenic diverticula (Herbella et al., Diseases of the Esophagus, 2012). In a Mayo Clinic series of 1,249 Zenker's patients, the rate was 0.4% (Huang et al., Annals of Thoracic Surgery, 1984). Risk is higher with older age, male sex, long-standing disease, and larger diverticula (Herbella et al., Diseases of the Esophagus, 2012).

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Many diverticula cause no symptoms and are found by chance. As many as 40% of epiphrenic diverticula are found incidentally. The size of the pouch doesn't reliably predict how bad the symptoms will be (Holmes et al., Neurogastroenterology & Motility, 2020).

Upper (Zenker's and Killian-Jamieson) diverticula typically cause (Hirano, Yamada's Textbook of Gastroenterology, 2022):

• Difficulty swallowing high in the throat

• Regurgitation of undigested food, sometimes hours after eating

• Bad breath (halitosis) from trapped food

• Gurgling sounds in the neck when swallowing, or a soft neck lump

• Coughing or choking while eating or lying down

• Hoarseness and recurrent pneumonia

Middle and lower (midesophageal and epiphrenic) diverticula typically cause (Yuan et al., Digestive Diseases and Sciences, 2024):

• Difficulty swallowing, the most common symptom, in about 71% of patients

• Regurgitation, in about 38%

• Weight loss and chest pain

• Gurgling behind the breastbone

• Heartburn-like symptoms that may be mistaken for ordinary reflux

Warning signs that need prompt evaluation: a sudden worsening of swallowing or regurgitation, pain, blood in regurgitated material, vomiting blood, or coughing up blood. These can signal ulceration or cancer in the pouch (Law et al., Clinical Gastroenterology and Hepatology, 2014).

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• Barium esophagram (swallow study): this is the key test. It shows the diverticulum's location, size, and how much contrast stays trapped in it (Antunes and Sloan, Current Gastroenterology Reports, 2023). The study must include the throat (hypopharynx), which isn't part of every routine esophagram, or a Zenker's diverticulum can be missed (Hirano, Yamada's Textbook of Gastroenterology, 2022).

• Telling Zenker's from Killian-Jamieson: front and side views on the esophagram, sometimes with a neck CT scan, show whether the pouch sits above (Zenker's) or below (Killian-Jamieson) the cricopharyngeus. That distinction changes the operation (Antunes and Sloan, Current Gastroenterology Reports, 2023). A Killian-Jamieson diverticulum can even look like a thyroid nodule on ultrasound.

• Upper endoscopy (EGD): this checks the lining for inflammation, ulceration, or cancer and looks for other problems. It's done carefully, because the diverticulum opening can trap the scope (Hirano, Yamada's Textbook of Gastroenterology, 2022).

• High-resolution esophageal manometry: this test is essential for midesophageal and epiphrenic diverticula. It measures how the esophagus squeezes and how the lower sphincter relaxes. In one study, 58% of patients with esophageal diverticula had a motility disorder, with achalasia the most common. Patients with epiphrenic diverticula had more achalasia and worse symptoms (Yuan et al., Digestive Diseases and Sciences, 2024). Some motility disorders only show up with provocative testing, such as solid-food swallows or rapid drinking (Baravian et al., Neurogastroenterology & Motility, 2025).

• CT scan of the chest: this helps plan surgery for thoracic diverticula and checks for scarred lymph nodes, fistula, or masses.

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• Achalasia: may cause a diverticulum or exist alongside one.

• Esophagogastric junction outflow obstruction (EGJOO)

• Diffuse esophageal spasm and jackhammer esophagus

• Cricopharyngeal bar or cricopharyngeal dysfunction without a pouch

• Esophageal stricture or Schatzki ring

• Eosinophilic esophagitis

• Esophageal cancer: this must be ruled out when symptoms are progressive or there's bleeding.

• GERD and laryngopharyngeal reflux (LPR)

• Hiatal or paraesophageal hernia: these can also cause regurgitation and food sticking, and they sometimes occur together with a diverticulum (Bock et al., Dysphagia, 2016).

• Neurologic swallowing disorders, such as after a stroke or with Parkinson's disease

• Thyroid nodule: Killian-Jamieson diverticula can mimic one (Antunes and Sloan, Current Gastroenterology Reports, 2023).

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No diet or medication can shrink or close a diverticulum. For patients with mild symptoms, or while waiting for treatment, these practical measures can reduce food trapping and aspiration risk:

• Eat slowly, take small bites, and chew thoroughly.

• Drink liquids with meals to help clear food from the pouch.

• Stay upright for 2–3 hours after eating and avoid late-night meals.

• Raise the head of your bed if you regurgitate at night.

• Take pills with plenty of water, one at a time, and ask whether a liquid form is available. Pills can lodge in the pouch (Law et al., Clinical Gastroenterology and Hepatology, 2014).

• Treat reflux if you have it.

• Tell every doctor, anesthesiologist, and endoscopist about your diverticulum before any procedure involving tubes or scopes (Hirano, Yamada's Textbook of Gastroenterology, 2022).

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Small diverticula that cause no symptoms can usually be watched (Hirano, Yamada's Textbook of Gastroenterology, 2022). Symptomatic diverticula need a procedure. The choice depends on the type, size, and location of the diverticulum, the underlying motility disorder, and your overall health.

The core principle for every type: the procedure must relieve the high-pressure zone that created the pouch. Removing the pouch alone risks recurrence and leaks. Relieving pressure alone may leave a pouch that still traps food (Pandolfino et al., Yamada's Textbook of Gastroenterology, 2022).

Zenker's diverticulum:

The key step is a cricopharyngeal myotomy, which divides the tight upper sphincter muscle (Bhatt et al., JAMA Otolaryngology–Head & Neck Surgery, 2021).

• Flexible endoscopic septotomy (FES): done through a flexible scope, with no neck incision. The surgeon divides the wall (septum) between the pouch and the esophagus, so the pouch becomes part of the esophagus, and cuts the sphincter muscle in the same step.

• Z-POEM (Zenker's peroral endoscopic myotomy): the muscle is divided through a tunnel under the lining, which leaves the lining intact. Reported clinical success is 85.5–93%, with major complications in about 5% (Ramamurthy et al., Journal of Clinical Medicine, 2025). Tunneling techniques had higher clinical success than standard septotomy (risk ratio 1.15) and similar complication rates (Delgado et al., Gastrointestinal Endoscopy, 2025).

• Rigid endoscopic stapling: done through the mouth with a stapler. It's best for diverticula between about 3 and 6 cm (Pandolfino et al., Yamada's Textbook of Gastroenterology, 2022). It may not be possible in patients with limited neck extension, extensive dental work, or a small mouth opening (Aaron et al., American College of Surgeons, 2021).

• Open transcervical surgery: done through a neck incision. The surgeon performs a myotomy plus removal (diverticulectomy) or suspension (diverticulopexy) of the pouch. Good to excellent results occur in 80–100% of patients (Pandolfino et al., Yamada's Textbook of Gastroenterology, 2022). Complications can reach 30%, and recovery is longer (Ramamurthy et al., Journal of Clinical Medicine, 2025).

• How they compare: in a 2026 multicenter matched study, flexible endoscopy had clinical success similar to open surgery (84.6% vs 88.9%) and better than rigid endoscopy (55.6%). It also had the shortest hospital stay (median 0 days vs 1 day for rigid and 3 days for open) and the fewest adverse events (Nuako et al., American Journal of Gastroenterology, 2026). Flexible endoscopic methods are increasingly favored as first-line treatment for symptomatic Zenker's (Zhang et al., Surgical Endoscopy, 2022).

Killian-Jamieson diverticulum:

Because this pouch sits next to the recurrent laryngeal nerve, the open transcervical approach has historically been preferred to protect the voice (Haddad et al., Annals of Otology, Rhinology & Laryngology, 2020). In a 2026 systematic review of 86 patients, both open and endoscopic approaches achieved high symptom control, with an overall failure rate of 3.5%. Endoscopic treatment allowed earlier eating and shorter hospital stays, and complete resolution was reported more often after open surgery (Zahlaka et al., Otolaryngology–Head and Neck Surgery, 2026).

Midesophageal and epiphrenic (thoracic) diverticula:

• Minimally invasive diverticulectomy with myotomy: the standard for symptomatic thoracic diverticula. Through laparoscopic, thoracoscopic, or robotic small incisions, the surgeon:
  1. Removes the pouch with a stapler (diverticulectomy)
  2. Performs a long esophageal myotomy, similar to a Heller myotomy, on the side opposite the staple line to relieve the high-pressure zone
  3. Usually adds a partial fundoplication (Dor or Toupet) to prevent reflux after the myotomy

• Why the myotomy matters: relieving the outflow obstruction protects the staple line from leaks and prevents recurrent pouch formation (Aiolfi et al., Surgical Endoscopy, 2026).
• Outcomes:
  • In a 15-year series of 57 patients, 86% had a motility disorder or distal obstruction. With minimally invasive surgery, 30-day mortality was 0%, the leak rate requiring reoperation was 7%, and dysphagia improved significantly (Macke et al., Annals of Thoracic Surgery, 2015).
  • In a 20-year laparoscopic series of 27 patients, 88.9% had myotomy and 85.2% had an antireflux procedure. There were no leaks or recurrences, and symptoms resolved in about 90% (Kao et al., American Surgeon, 2018).
  • By comparison, open repair through the chest has reported leak rates up to 21% and mortality up to 11% (Broderick et al., Journal of Laparoendoscopic & Advanced Surgical Techniques, 2024).
  • Even with these risks, surgery provides better long-term swallowing and lower symptom recurrence than conservative care (Nitsche et al., Surgery, 2022).

• Diverticular POEM (D-POEM): an endoscopic tunneling technique that divides the septum and the underlying muscle without external incisions. Early results are promising, with 90% clinical remission in a small series (Liu et al., BMC Gastroenterology, 2025), but long-term data are limited. It may suit high-risk or elderly patients.

• Treating the underlying disorder: when achalasia is present, the myotomy treats both conditions. Small diverticula may need only the myotomy.

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See a doctor if you have:

• Difficulty swallowing, or food that feels stuck in your throat or chest

• Regurgitation of undigested food, especially hours after eating

• Persistent bad breath that doesn't improve with dental care

• Gurgling in your neck or chest when swallowing

• Coughing or choking when eating or lying down

• Unexplained weight loss

• Recurrent pneumonia or chronic cough

You should also see a doctor if a diverticulum was found on an imaging study, even without symptoms. You'll need a baseline evaluation and, for thoracic diverticula, a check for an underlying motility disorder.

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Seek treatment when:

• The diverticulum causes swallowing problems, regurgitation, or weight loss that affect your daily life

• You've had aspiration or pneumonia

• Pills are lodging or your medications aren't working reliably

• Testing shows a motility disorder such as achalasia that needs treatment anyway

Seek emergency care for:

• Vomiting blood or coughing up blood

• Complete inability to swallow liquids or your own saliva

• Chest pain with fever after a procedure or a food impaction

• Severe shortness of breath after a choking episode

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• Recurrence is uncommon when the pressure problem is fixed. The most common cause of recurrence is an incomplete myotomy or a leftover septum (Pandolfino et al., Yamada's Textbook of Gastroenterology, 2022).

• Underlying motility disorders such as achalasia are lifelong conditions. They need ongoing follow-up even after successful treatment.

• Cancer can rarely develop even after treatment. Patients who have had a diverticulum should report any new or worsening swallowing problems promptly (Herbella et al., Diseases of the Esophagus, 2012).

• If a recurrence happens, it can usually be treated endoscopically or surgically, often with minimally invasive techniques.

Related Reading and Videos

Read more in our articles GERD vs. Heartburn vs. Acid Reflux: What's the Difference (and When It's Serious) and When Does Acid Reflux Need Surgery? A Guide to Your Options (Nissen, Toupet, LINX, and TIF). Watch The Reflux Talk Every Patient Needs: Hiatal Hernias, Warning Signs & What Doctors Don’t Explain on our video library. Related conditions include Jackhammer Esophagus, Achalasia and Dysphagia (Difficulty Swallowing). Treatments that may be involved include Esophageal Diverticulum, Esophageal Dilation (Endoscopic Balloon & Bougie Dilation for Strictures & Dysphagia) and Foregut Surgery.

More Foregut and Reflux Conditions

Explore related topics in our foregut patient library: Gastroparesis, Dysphagia (Difficulty Swallowing), Achalasia, Paraesophageal Hernia, Strictures of the Esophagus, Pylorus and Duodenum and Esophageal Cancer. For an overview of surgical options, see anti-reflux surgery and hiatal and paraesophageal hernia repair.

For symptomatic diverticula, treatment works well.

• Zenker's diverticulum: endoscopic and open treatments relieve symptoms in most patients. Reported success is 85–93% for Z-POEM and 90–95% for open surgery (Ramamurthy et al., Journal of Clinical Medicine, 2025).

• Epiphrenic and midesophageal diverticula: minimally invasive diverticulectomy with myotomy resolves symptoms in about 90% of patients in experienced centers (Kao et al., American Surgeon, 2018).

Untreated symptomatic diverticula tend to progress. Conservatively treated patients with epiphrenic diverticula had significantly more symptom recurrence or progression than surgical patients (Nitsche et al., Surgery, 2022).

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An esophageal diverticulum is rarely just a pouch. It's usually a pressure problem. Lasting success depends on finding the cause and treating it: cricopharyngeal dysfunction, achalasia, EGJOO, or esophageal spasm. That takes complete foregut expertise, not just a stapler.

Dr. Nestor de la Cruz-Muñoz, MD, FACS, DABOM, is a foregut and minimally invasive surgeon in Miami. Antireflux and esophageal surgery is the center of his practice, and he served as a surgical fellowship program director for 10 years, teaching advanced minimally invasive techniques to the next generation of surgeons. His approach to esophageal diverticula includes:

• A complete evaluation: a barium esophagram that includes the throat, upper endoscopy, and high-resolution manometry, so the underlying motility disorder is diagnosed before anything is done

• Minimally invasive diverticulectomy with myotomy and partial fundoplication for midesophageal and epiphrenic diverticula. These are the same Heller myotomy, Dor, and Toupet techniques he uses for achalasia and reflux.

• Matching the procedure to the pouch: endoscopic or surgical options for Zenker's and Killian-Jamieson diverticula, coordinated with expert endoscopic and head-and-neck colleagues when that's the best path

• Treating associated conditions such as hiatal hernia and reflux in the same plan

• Long-term follow-up for underlying motility disorders

If you've been told you have an esophageal diverticulum, or you're living with regurgitation and swallowing problems nobody has explained, schedule an evaluation to find out exactly what's causing it and how to fix it.

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Across a career of over 25 years, Dr. de la Cruz-Muñoz has completed over 15,000 minimally invasive procedures. That experience covers complex foregut surgery, the field most relevant to esophageal diverticula, along with hernia, gallbladder, abdominal and bariatric operations.