epiphrenic esophageal diverticula ( eed ) are out - pouching of the esophageal lumen , originating in the distal of the esophagus , typically 4 - 8 cm above the cardia and usually projecting from the right posterior wall . the actual incidence of eed is unknown , but , the estimated incidence is about 1:500,000/year . we present a case with a long history of symptoms which caused by epiphrenic diverticulum . the present case report is about a 48-year - old male patient who was admitted in the clinic of internal medicine at amir - ul - momenin hospital , zabol , iran on june 2013 with a body mass index of 42.6 . symptoms had started since 20 years ago , but worsened during the last 6 months , especially after meals . the pain sometimes radiated to the lower - left side of the chest and the upper quadrants of the abdomen , which aggravated after eating a big meal . besides antacids and h2 receptor antagonists such as cimetidine , the pain often alleviated after eructation and regurgitation . a barium swallow demonstrated an epiphrenic driverticulum of 42 mm at the right side of sternum [ figure 1 ] . in addition , he complained of a severe constipation and rectal bleeding after barium esophagography . the complete blood count test revealed a hematocrit of 47.4% and hemoglobin of 16.3 g / dl . a panendoscopy showed a hiatus hernia and erythematous mucosa in the body of the stomach . a biopsy of gastric antral erythematous mucosa showed a moderate chronic active superficial gastritis and mild atrophy . treatment team was not consent whether the patient must undergo for an early diverticulectomy due to the size of diverticulum and the moderate - severe symptoms . the symptoms were improved after 2 weeks of prescription of pantaprazole sodium 80 mg bid and teaching to change the food habits such as chewing food thoroughly and drinking plenty of water after meals . eed usually result from a combination of esophageal obstruction , functional or mechanical and a point of weakness of the muscularis propria . all or only the mucosa and submucosal layers of the esophagus may involve as well . the functional obstruction is associated with motility disorders e.g. , achalacia , diffuse spasm , hypertensive lower esophageal sphincter ( les ) , non - specific motility disorders , uncoordinated and poorly relaxing les with very high - pressure peristaltic waves . the mechanical obstruction is associated with a prior nissen fundoplication , peptic stricture and leiomyoma or gastroesophageal junction tumor . in some patients the other symptoms are regurgitation , weight loss , chest pain , halitosis , aspiration , anorexia , hematemesis , heartburn , melena , nocturnal cough and odynophagia patients with a diverticulum larger than 5 cm are usually symptomatic . however , most of patients with eed are asymptomatic . as the symptoms are common and unspecific , late diagnosis can cause more severe and potentially life - threatening illnesses e.g. , aspiration pneumonia and cancer . the warning symptoms are progressive dysphagia , unintentional weight loss , blood in the regurgitated material , regurgitation of a piece of the tumor , odynophagia , melena , hematemesis and hemoptysis . risk factors for malignancy are old age , men , long - standing history and larger diverticula . however , some of the researchers did not find esophageal carcinoma arising within a diverticulum . barium swallow is a brilliant , safe , simple and effective test to diagnose and determine the size and location of eed . however , barium is associated with constipation and barium impaction . drinking plenty of water and using a stool softener or laxative promote evacuation of barium . upper digestive endoscopy confirms the presence of diverticula , and rules out malignancy and associated diseases . esophageal manometry is the other excellent test for diagnosing the esophageal motor disorders . in symptomatic patients , ph monitoring diagnoses gastroesophageal reflux disease and guides medical treatments . however , some authors obviate manometry or ambulatory ph monitoring because they believe motor disorder is always present in patient with eed and the results usually do not affect the planned procedures . no specific treatment needs for asymptomatic small and mildly symptomatic medium - sized diverticula , but symptoms of reflux or gastritis should be managed using proton pump inhibitors or h2-blockers . endoscopic pneumatic dilation and botulinum toxin injection are a good alternative for symptomatic patients with motility disorders who are unfit for or unwilling to undergo surgery . the presence of diverticulum , per se and its size are not indications for surgery in the patient with eed . surgery should be for patients with large diverticula , severe dysphagia , regurgitation , food retention and the actual or potential risk of aspiration pneumonia . treatment strategies , surgical or laparoscopic , in patient with symptomatic eed involve esophageal myotomy , diverticulectomy and fundoplication . myotomy decreases the incidence of diverticulum recurrence and partial fundoplication has been proposed as the most appropriate antireflux method . laparoscopy is the best approach for diverticulectomy , esophageal myotomy and fundoplication , when diverticula are < 4 cm across the base and closer to the esophageal hiatus . this approach offers better exposure of the esophagus in patients with midesophageal diverticula , previous abdominal surgery and morbid obesity . proton pump inhibitors are maintained indefinitely and all medications are prescribed in crushed or liquid form , avoiding pills . the current case not only adds to the collective clinical knowledge of this rare esophageal disorder , but also reveals a considerable perspective on relieving symptoms through conservative treatments . patient was symptomatic despite having a diverticulum < 5 cm and there was no evidence for malignancy regardless of having risk factors i.e. , old age , men , long - standing history and delayed diagnosis . therefore , this kind of treatment should always be the first line management even for the symptomatic patients . the patient with eed must consume plenty of water after the meal to wash out the food remnants from esophageal diverticula . although chest pain is unspecific , patients must be oriented that it might be a critical symptom of myocardial infarction and must seriously be assessed and managed in referral centers . to prevent the complications of barium esophagography such as constipation and barium impaction finally , if symptoms persist and the risk of aspiration pneumonia presents , operation becomes the alternative treatment method . all authors have assisted in preparation of the first draft of the manuscript or revising it critically for important intellectual content . all authors have read and approved the content of the manuscript and confirmed the accuracy or integrity of any part of the work .
epiphrenic esophageal diverticula ( eed ) are rare . 
 the estimated incidence is about 1:500,000/year . 
 eed usually result from a combination of esophageal obstruction , functional or mechanical and a point of weakness of the muscularis propria . 
 most of the symptoms are unspecific , but dysphagia is most common . 
 chest radiograph , barium esophagogram , endoscopy and manometry are diagnostic tools . 
 the treatment methods are conservative medical therapy , myotomy , diverticulectomy and fundoplication . 
 in addition , endoscopic pneumatic dilation and botulinum toxin injection are a good alternative for symptomatic patients with motility disorders who are unfit for or unwilling to undergo surgery .