Bleeding Zenker’s Diverticulum Ulcer from Nonsteroidal Anti-Inflammatory Drugs

A 70-year-old man presented for hematemesis that began the night prior. He reported several large bloody vomitus originating from his throat with a globus sensation. He was recently started on aspirin and clopidogrel for a transient ischemic attack. On arrival his vitals were stable and his physical exam was unremarkable. He was actively spitting up copious amounts of blood. Lab results showed hemoglobin 12.1 g/dL, hematocrit 36.2%, blood urea nitrogen 28 mg/dL, and international normalized ratio 1.0. A chest X-ray was notable for a superior widened mediastinum with tracheal deviation. Given the ongoing bleeding and the suspicion of a proximal source, an elective intubation was performed to secure the airway for an esophagogastroduodenoscopy. A large Zenker’s diverticulum (ZD) was seen 17 cm from the incisors with copious amounts of blood and clot (Figure 1). After clearance, two shallow base ulcers were identified, one with an adherent clot (Figure 2). The clot was irrigated and no further bleeding was observed. There was no stigmata of recent hemorrhage identified in the stomach or the visualized portion of the duodenum. Given the proximal location of the ulcers, the relative stability of the clot, and the uncertainty of the surrounding anatomy, further endoscopic management was deferred and the patient was referred to surgery for discussion of a diverticulectomy. Aspirin and clopidogrel were held and he remained on twice-daily intravenous pantoprazole for a total of 5 days prior to discharge. The patient has remained asymptomatic in follow-up; aspirin was permanently discontinued, clopidogrel was restarted, and the otolaryngologist decided to forego surgical intervention