# Midesophageal diverticulum with elevated intrabolus pressure: a case report

## TL;DR

A patient with a midesophageal diverticulum and high pressure in the esophagus was successfully treated with surgery and myotomy.

## Contribution

Highlights a case where esophageal surgery improved symptoms despite not meeting standard motility disorder criteria.

## Key findings

- A 71-year-old man with M-ED showed elevated intrabolus pressure but no motility disorder by Chicago classification.
- Thoracoscopic resection and myotomy reduced symptoms and normalized intrabolus pressure.
- HRM findings suggest esophageal diverticulum pathology should be considered even outside standard classification criteria.

## Abstract

Esophageal diverticulum is commonly associated with esophageal motility disorders, which can be diagnosed using high-resolution manometry (HRM) according to the Chicago classification. Although midesophageal diverticulum (M-ED) is associated with inflammatory processes, esophageal motility disorders have been recently identified as an etiology of M-ED.

We present the case of a patient with M-ED and elevated intrabolus pressure (IBP), which did not meet the criteria for esophageal motility disorders according to the Chicago classification. A 71-year-old man presented with gradually worsening dysphagia for two years and was diagnosed as having an 8-cm-long M-ED and multiple small diverticula in lower esophagus. HRM revealed a median integrated relaxation pressure of 14.6 mmHg, a distal latency of 6.4 s, and an average maximum IBP of 35.7 mmHg. He underwent thoracoscopic resection of the M-ED and myotomy, which successfully alleviated the symptoms and reduced the intrabolus pressure to normal levels.

It is important to recognize the esophageal diverticulum pathology with HRM findings even in cases where the results may not meet the Chicago classification and to include myotomy based on the results.