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A 68-year-old man was referred because of progressive dysphagia and regurgitation that had reached a stage at which he could no longer eat or drink without coughing and spluttering. He was receiving thyroxine-replacement therapy. Examination revealed undernourishment and myxedema. Blood tests confirmed the presence of hypothyroidism. Barium swallow demonstrated a large Zenker's diverticulum (Panel A). The patient was admitted for enteral feeding and thyroxine-replacement therapy administered through a nasogastric tube. After optimization of nutritional and thyroid states, he underwent an endoscopic diverticulotomy involving stapling. During passage of the diverticuloscope to expose the tissue bar between the esophagus and diverticulum, a thyroxine tablet was found trapped in the diverticulum (Panel B). Both the procedure and the postoperative course were free of complications. The patient has subsequently been euthyroid and swallows without difficulty. Endoscopic diverticulotomy with stapling may be considered as a therapeutic option for the management of a Zenker's diverticulum.
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