Esophageal diverticula, or herniations of the esophageal musoca, are hollow outpouchings of the esophageal wall that occur in three main areas of the esophagus: proximally near the anatomic hypopharyngeal sphincter (Zenker’s diverticulum, the most common location); near the midpoint of the esophagus (a midesophageal diverticulum); and just above the lower esophageal sphincter (an epiphrenic diverticulum, the least common location). Food, fluids, and secretions accumulate in these dilated outpouchings, creating discomfort. Aspiration pneumonia, bronchitis, bronchiectasis, and lung abscess may be the result of regurgitating contents of the esophageal diverticula. Esophageal diverticula may also lead to esophageal perforation.
Esophageal diverticula develop from weakened esophageal musculature (congenital and acquired), traumatic injury, and scar tissue associated with chronic inflammation. Developmental muscle weakness of the posterior pharynx above the border of the cricopharyngeal muscle leads to Zenker’s diverticulum. Pressure caused by swallowing and contraction of the pharynx before the sphincter relaxes aggravates the muscle weakness and results in the development of diverticula. A response to scarring and pulling on esophageal walls by an external inflammatory process such as tuberculosis or by traction from old adhesions may lead to midesophageal diverticula. Other causes of esophageal diverticula include motor disturbances such as achalasia (absence of normal peristalsis in esophageal smooth muscle and elevated pressure at the physiological cardiac sphincter), diffuse esophageal spasms, and reflux esophagitis.
Nursing care plan assessment and physical examination
Establish a recent history of weight loss, which is generally attributed to difficulty in eating. Determine if the patient has experienced subtle, gradually progressive esophageal dysphagia that primarily affected the swallowing of solid foods. Ask if the patient has experienced gagging, gurgling, or a sense of fullness in the throat as if something were “stuck.” Inquire whether the patient has regurgitated food particles and saliva soon after eating. Determine if the patient has experienced an unpleasant taste and nocturnal coughing with regurgitation of retained secretions and undigested foods. Establish a history of heartburn following ingestion of coffee, alcohol, chocolate, citrus juices, or fatty foods, particularly when the patient was bending over or lying down within 2 hours of intake. These indicators suggest that the esophageal diverticula are secondary to achalasia.
Assess the patient’s appearance, noting apparent weight loss or the malnourished look that is associated with anorexia. Note halitosis, a common sign of esophageal diverticula. Inspect the patient’s neck for visible signs of esophageal distension that has been caused by food trapped in the diverticula.
The patient may experience self-imposed social isolation because of feelings of embarrassment, which are caused by noisy swallowing, unusual facial expressions during eating, or halitosis. The patient may become depressed because of the loss of pleasure and socialization connected with eating, along with grieving over the loss of dietary preferences. The patient’s family may be anxious about the social effects of the patient’s disease as well.
Nursing care plan primary nursing diagnosis: Risk for aspiration related to regurgitation of food, fluid, or secretions that have accumulated in diverticula.
Nursing care plan intervention and treatment plan
When achalasia is implicated, pharmacologic therapy may be the first procedure. Assess the effects of treatments because the drugs may worsen the diverticula by relaxing an already weakened esophageal musculature.
An esophagomyotomy (incision into the esophageal musculature) and diverticulectomy (surgical removal of the diverticulum) may be warranted, particularly for patients with Zenker’s diverticulum. A cricopharyngeal myotomy, a procedure in which the surgeon divides the cricopharyngeal muscle, involves cutting the muscle to make it incompetent so that when the individual swallows, the muscle relaxes and allows food to pass through. Postoperative care is determined by the incisional approach. With a cervical approach, a drain is commonly inserted in the neck to diminish edema at the incisional site. A chest incision (thoracic approach) requires care associated with a thoracotomy. Postoperative care is directed at monitoring the patency of the airway, maintaining pulmonary ventilation by chest drainage with chest tubes, monitoring neck drainage with either gravity drainage or low suction, and preventing aspiration.
Care focuses on maintaining a patent airway, preventing aspiration of regurgitated food and mucus, providing emotional support, and providing adequate nutrition. Implement interventions to maintain airway patency if there is any suspicion it is at risk. Use the jaw thrust or chin lift, or insert an oral or nasal airway. Prevent aspiration of regurgitated food and mucus by positioning the patient carefully, with her or his head elevated or turned to one side. Recommend that the patient sleep with the head elevated (using pillows or bed blocks) to reduce esophageal reflux and nocturnal choking. Show the patient how to use massage to empty any visible outpouching to the neck to prevent aspiration during sleep.
Education, rather than medical or surgical intervention, may become the treatment of choice. Provide the patient with information on lifestyle changes to reduce symptoms. Teach appropriate nutrition. Advise the patient to explore textures and quantities of foods to determine which cause the least discomfort. Recommend that the patient consider semisoft and soft foods, and advise adding fiber to the diet to stimulate peristalsis of the gastrointestinal (GI) system, reducing lower GI tract pressure on the esophagus. Recommend food supplements between meals to prevent weight loss and malnourishment, and advise the patient to drink fluids intermittently with meals to aid in propulsion of the food bolus through the esophagus. Teach the patient to concentrate on the act of eating to maximize each phase of the process of ingesting food and fluids, moistening the mouth before eating to facilitate chewing and swallowing. Explain how to use Valsalva’s maneuver to increase esophageal pressure, thus facilitating food bolus movement beyond the hypopharyngeal sphincter. Recommend that the patient sit upright when eating or drinking to facilitate gravitational flow through the esophagus, and advise remaining upright for at least 2 hours after eating. Advise taking adequate fluids (>15 mL) with medications to prevent chemical esophageal irritation. Recommend eliminating oral drugs immediately before bedtime to decrease the risk of deposits in diverticula that can create ulceration. Advise the patient to avoid food or fluids within 3 to 4 hours of bedtime to reduce nocturnal symptoms.
Nursing care plan discharge and home health care guidelines
Teach the patient methods to reduce symptoms, prevent malnutrition and weight loss, and improve sleep and rest. Make sure the patient understands the dosage, route, action and purpose, side effects, and contraindications of the prescribed medications. Explain the potential for aspiration, respiratory impairment, weight loss or malnourishment, and sleep deprivation. Remind the patient to see the physician if symptoms of esophageal diverticula return or worsen.
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