Plummer-Vinson syndrome (PVS), or Paterson-Brown-Kelly syndrome, is a rare medical condition primarily affecting the upper digestive tract. It is characterized by symptoms, including dysphagia, iron-deficiency anemia, and thin, membranous tissue called esophageal webs within the throat. These esophageal webs can narrow the upper esophagus and cause further difficulty in swallowing.
The exact cause of Plummer-Vinson syndrome is not fully understood. However, it is thought to result from various factors, including nutritional deficiencies, genetic predisposition, and potential autoimmune processes. The syndrome is more commonly observed in middle-aged women, although cases have been reported in individuals of various ages and genders.
A significant concern associated with Plummer-Vinson syndrome is its connection to an increased risk of developing squamous cell carcinoma in the pharynx and proximal esophagus. While the exact link between PVS and cancer is not fully understood, the chronic inflammation and irritation caused by the condition’s features, including the esophageal webs and nutritional deficiencies, are believed to contribute to the heightened cancer risk.
Epidemiology
Plummer-Vinson syndrome is a relatively rare condition, and its exact prevalence is not well-defined. However, it is generally considered to be uncommon. PVS predominantly affects women, particularly those in middle age, although cases have been reported in individuals of various ages and genders. The syndrome’s higher incidence in women suggests a potential hormonal or gender-related predisposition, but the exact mechanisms are not fully understood.
Plummer-Vinson syndrome exhibited a higher occurrence in the first half of the 20th century, particularly among middle-aged women of Scandinavian origin. The prevalence of this syndrome experienced a rapid decline in the latter half of the 20th century, attributed to boosted nutritional awareness, notably the widespread enrichment of flour with iron. PVS has primarily been documented within the Caucasian demographic, with a predominant occurrence in women.
In earlier investigations in Scandinavian populations, as much as 90% of individuals afflicted with PVS were reported to be women. Typically, the syndrome is diagnosed in the age range of 40 to 70 years, although a limited number of cases have been identified in children. Geographically, Plummer-Vinson syndrome has been reported in various parts of the world, although it may be more prevalent in certain regions. It has been associated with nutritional deficiencies, particularly iron deficiency, which can be influenced by factors such as dietary habits and socioeconomic status.
As access to healthcare and nutrition improves, the prevalence of PVS may decrease, given that one of its underlying causes is iron-deficiency anemia. Because Plummer-Vinson syndrome is rare and often goes undiagnosed or misdiagnosed due to its varied and non-specific symptoms, it’s challenging to provide precise epidemiological data. Medical literature and databases may contain varying estimates of its prevalence, and the condition might be underreported.
Anatomy
Pathophysiology
Iron deficiency anemia is a hallmark of PVS. Chronic blood loss from the esophageal webs, which can cause small amounts of bleeding, contributes to this anemia. The esophageal webs themselves may result from long-term iron and other nutrient deficiencies. Iron is essential for properly functioning hemoglobin, the molecule responsible for transporting oxygen in the blood. Inadequate iron levels can lead to anemia, resulting in fatigue, weakness, and other related symptoms.
PVS appears to have a gender and age predisposition, which is more common in middle-aged women. This suggests potential hormonal or genetic influences on the development of the syndrome. However, specific genes associated with PVS have not been definitively identified. PVS has been associated with various autoimmune and immune-mediated disorders, such as celiac disease, Crohn’s disease, rheumatoid arthritis, and thyroid diseases.
This has led to speculation about immune dysregulation playing a role in the development of PVS. The immune system’s involvement in chronic inflammation and tissue damage could contribute to the formation of esophageal webs and other characteristic features of the syndrome.
Etiology
Even after a century since the initial reports of cases, the exact cause of Plummer-Vinson syndrome’s (PVS) development remains elusive. Various theories have been proposed to explain its origin, including nutritional and iron deficiencies, genetic predisposition, and potential autoimmunity. However, the supporting evidence for these hypotheses is generally limited, with the exception of iron deficiency, which consistently emerges as a significant factor.
This is partly due to studies indicating that dysphagia tends to improve with iron supplementation, while iron deficiency is thought to contribute to mucositis, possibly leading to the formation of esophageal webs. Given that individuals with PVS may experience malnutrition, some researchers have posited vitamin B deficiency as a potential causative factor. Furthermore, Plummer-Vinson syndrome has been associated with celiac disease, Crohn’s disease, rheumatoid arthritis, and thyroid disorders.
This association hypothesizes that immune dysregulation might be involved in the syndrome’s development, although this aspect remains unproven. In all instances, it is crucial to investigate the underlying reasons for the iron deficiency seen in PVS patients. This includes exploring potential causes such as gastrointestinal bleeding and conditions like celiac disease. Despite ongoing research efforts, the precise cause of Plummer-Vinson syndrome remains unknown, necessitating further exploration to unravel its complex pathogenesis.
Genetics
Prognostic Factors
Clinical History
Clinical History
Individuals with Plummer-Vinson syndrome often present with a history of chronic symptoms related to their upper digestive tract and overall health. These symptoms may develop gradually and worsen over time. Dysphagia is a hallmark symptom of PVS. Individuals may complain of a sensation of food sticking in the throat or chest while eating, which can lead to discomfort and reduced food intake. Iron deficiency anemia is a common consequence of PVS due to chronic blood loss from the esophageal webs.
Anemic symptoms might include fatigue, weakness, pale skin, and shortness of breath. The onset and duration of Plummer-Vinson syndrome can vary among individuals. Generally, the syndrome develops over time, and symptoms worsen gradually. The age at onset can vary, but it is typically observed in individuals between the ages of 40 and 70. However, cases have been reported in people of different ages, including children, although these are rare. Without intervention, the symptoms of PVS can persist and potentially worsen over an extended period.
Physical Examination
Physical Examination
Anemia, particularly iron deficiency anemia, is a key component of PVS. This can lead to a pale appearance of the skin and mucous membranes. Also known as spoon nails, koilonychia refers to nails that are concave and have a scooped-out appearance. Cracks and inflammation at the corners of the mouth can indicate nutritional deficiencies, including iron deficiency.
Anemia can lead to general weakness and fatigue. Patients might appear tired and have reduced energy levels. Anemia can result in tachycardia as the heart tries to compensate for the decreased oxygen-carrying capacity of the blood. Splenomegaly might be observed in severe PVS cases due to chronic anemia’s effects on blood cells and the circulatory system. However, this finding is rare.
Age group
Associated comorbidity
Associated activity
Acuity of presentation
Differential Diagnoses
Differential Diagnoses
Achalasia
Gastroesophageal reflux disease
Hypopharyngeal bar
Scleroderma
Laboratory Studies
Imaging Studies
Procedures
Histologic Findings
Staging
Treatment Paradigm
Treatment
(Administration of pharmaceutical agent section)
Iron Supplementation
The medical approach to managing Plummer-Vinson syndrome involves the administration of iron supplements. As part of the management process, healthcare professionals typically investigate the potential presence of occult or overt blood loss, rule out underlying malignancies, and assess for iron malabsorption. The administration of iron replacement therapy is crucial for addressing anemia and resolving the various manifestations associated with iron deficiency.
While the necessity for ongoing iron replacement remains uncertain beyond anemia correction, ensuring proper anemia management is vital. Usually, a dose of elemental iron ranging from 150 to 200 mg is required to effectively rectify iron deficiency anemia. Notably, dysphagia, a prevalent symptom in many patients, often eases with the sole intervention of iron supplementation. This approach focuses on addressing the core nutritional deficiency underlying Plummer-Vinson syndrome and can lead to the resolution of multiple related symptoms.
Surgical Care
Individuals experiencing advanced and long-standing dysphagia typically necessitate mechanical dilation as part of their treatment. Commonly employed methods for dilation encompass endoscopic balloon dilatation or the use of Savary-Gilliard dilators. The term therapeutic endoscopy refers to the intentional disruption of the esophageal web, often resulting in a minor amount of fresh blood appearing on the web site.
While the esophageal web can sometimes be broken by the mere insertion of an endoscope into the esophagus, more challenging cases might require the use of a bougie, which has demonstrated efficacy. In most instances, employing a solitary large dilator proves adequate and frequently yields superior results compared to a progressive dilation approach conducted sequentially.
Dietary Modification
In addition to iron supplementation, dietary adjustments can effectively address the needs of mildly symptomatic patients. It is recommended that patients adopt the practice of eating slowly and thoroughly chewing their food. Particular attention should be given to preparing solids, which should be sliced into smaller portions, mainly when dealing with meats. Surgical intervention is a rare consideration, primarily reserved for cases in which dilation proves ineffective in managing esophageal webs, or when these webs are connected with Zenker diverticulum.
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Plummer-Vinson syndrome (PVS), or Paterson-Brown-Kelly syndrome, is a rare medical condition primarily affecting the upper digestive tract. It is characterized by symptoms, including dysphagia, iron-deficiency anemia, and thin, membranous tissue called esophageal webs within the throat. These esophageal webs can narrow the upper esophagus and cause further difficulty in swallowing.
The exact cause of Plummer-Vinson syndrome is not fully understood. However, it is thought to result from various factors, including nutritional deficiencies, genetic predisposition, and potential autoimmune processes. The syndrome is more commonly observed in middle-aged women, although cases have been reported in individuals of various ages and genders.
A significant concern associated with Plummer-Vinson syndrome is its connection to an increased risk of developing squamous cell carcinoma in the pharynx and proximal esophagus. While the exact link between PVS and cancer is not fully understood, the chronic inflammation and irritation caused by the condition’s features, including the esophageal webs and nutritional deficiencies, are believed to contribute to the heightened cancer risk.
Plummer-Vinson syndrome is a relatively rare condition, and its exact prevalence is not well-defined. However, it is generally considered to be uncommon. PVS predominantly affects women, particularly those in middle age, although cases have been reported in individuals of various ages and genders. The syndrome’s higher incidence in women suggests a potential hormonal or gender-related predisposition, but the exact mechanisms are not fully understood.
Plummer-Vinson syndrome exhibited a higher occurrence in the first half of the 20th century, particularly among middle-aged women of Scandinavian origin. The prevalence of this syndrome experienced a rapid decline in the latter half of the 20th century, attributed to boosted nutritional awareness, notably the widespread enrichment of flour with iron. PVS has primarily been documented within the Caucasian demographic, with a predominant occurrence in women.
In earlier investigations in Scandinavian populations, as much as 90% of individuals afflicted with PVS were reported to be women. Typically, the syndrome is diagnosed in the age range of 40 to 70 years, although a limited number of cases have been identified in children. Geographically, Plummer-Vinson syndrome has been reported in various parts of the world, although it may be more prevalent in certain regions. It has been associated with nutritional deficiencies, particularly iron deficiency, which can be influenced by factors such as dietary habits and socioeconomic status.
As access to healthcare and nutrition improves, the prevalence of PVS may decrease, given that one of its underlying causes is iron-deficiency anemia. Because Plummer-Vinson syndrome is rare and often goes undiagnosed or misdiagnosed due to its varied and non-specific symptoms, it’s challenging to provide precise epidemiological data. Medical literature and databases may contain varying estimates of its prevalence, and the condition might be underreported.
Iron deficiency anemia is a hallmark of PVS. Chronic blood loss from the esophageal webs, which can cause small amounts of bleeding, contributes to this anemia. The esophageal webs themselves may result from long-term iron and other nutrient deficiencies. Iron is essential for properly functioning hemoglobin, the molecule responsible for transporting oxygen in the blood. Inadequate iron levels can lead to anemia, resulting in fatigue, weakness, and other related symptoms.
PVS appears to have a gender and age predisposition, which is more common in middle-aged women. This suggests potential hormonal or genetic influences on the development of the syndrome. However, specific genes associated with PVS have not been definitively identified. PVS has been associated with various autoimmune and immune-mediated disorders, such as celiac disease, Crohn’s disease, rheumatoid arthritis, and thyroid diseases.
This has led to speculation about immune dysregulation playing a role in the development of PVS. The immune system’s involvement in chronic inflammation and tissue damage could contribute to the formation of esophageal webs and other characteristic features of the syndrome.
Even after a century since the initial reports of cases, the exact cause of Plummer-Vinson syndrome’s (PVS) development remains elusive. Various theories have been proposed to explain its origin, including nutritional and iron deficiencies, genetic predisposition, and potential autoimmunity. However, the supporting evidence for these hypotheses is generally limited, with the exception of iron deficiency, which consistently emerges as a significant factor.
This is partly due to studies indicating that dysphagia tends to improve with iron supplementation, while iron deficiency is thought to contribute to mucositis, possibly leading to the formation of esophageal webs. Given that individuals with PVS may experience malnutrition, some researchers have posited vitamin B deficiency as a potential causative factor. Furthermore, Plummer-Vinson syndrome has been associated with celiac disease, Crohn’s disease, rheumatoid arthritis, and thyroid disorders.
This association hypothesizes that immune dysregulation might be involved in the syndrome’s development, although this aspect remains unproven. In all instances, it is crucial to investigate the underlying reasons for the iron deficiency seen in PVS patients. This includes exploring potential causes such as gastrointestinal bleeding and conditions like celiac disease. Despite ongoing research efforts, the precise cause of Plummer-Vinson syndrome remains unknown, necessitating further exploration to unravel its complex pathogenesis.
Clinical History
Individuals with Plummer-Vinson syndrome often present with a history of chronic symptoms related to their upper digestive tract and overall health. These symptoms may develop gradually and worsen over time. Dysphagia is a hallmark symptom of PVS. Individuals may complain of a sensation of food sticking in the throat or chest while eating, which can lead to discomfort and reduced food intake. Iron deficiency anemia is a common consequence of PVS due to chronic blood loss from the esophageal webs.
Anemic symptoms might include fatigue, weakness, pale skin, and shortness of breath. The onset and duration of Plummer-Vinson syndrome can vary among individuals. Generally, the syndrome develops over time, and symptoms worsen gradually. The age at onset can vary, but it is typically observed in individuals between the ages of 40 and 70. However, cases have been reported in people of different ages, including children, although these are rare. Without intervention, the symptoms of PVS can persist and potentially worsen over an extended period.
Physical Examination
Anemia, particularly iron deficiency anemia, is a key component of PVS. This can lead to a pale appearance of the skin and mucous membranes. Also known as spoon nails, koilonychia refers to nails that are concave and have a scooped-out appearance. Cracks and inflammation at the corners of the mouth can indicate nutritional deficiencies, including iron deficiency.
Anemia can lead to general weakness and fatigue. Patients might appear tired and have reduced energy levels. Anemia can result in tachycardia as the heart tries to compensate for the decreased oxygen-carrying capacity of the blood. Splenomegaly might be observed in severe PVS cases due to chronic anemia’s effects on blood cells and the circulatory system. However, this finding is rare.
Differential Diagnoses
Achalasia
Gastroesophageal reflux disease
Hypopharyngeal bar
Scleroderma
Treatment
(Administration of pharmaceutical agent section)
Iron Supplementation
The medical approach to managing Plummer-Vinson syndrome involves the administration of iron supplements. As part of the management process, healthcare professionals typically investigate the potential presence of occult or overt blood loss, rule out underlying malignancies, and assess for iron malabsorption. The administration of iron replacement therapy is crucial for addressing anemia and resolving the various manifestations associated with iron deficiency.
While the necessity for ongoing iron replacement remains uncertain beyond anemia correction, ensuring proper anemia management is vital. Usually, a dose of elemental iron ranging from 150 to 200 mg is required to effectively rectify iron deficiency anemia. Notably, dysphagia, a prevalent symptom in many patients, often eases with the sole intervention of iron supplementation. This approach focuses on addressing the core nutritional deficiency underlying Plummer-Vinson syndrome and can lead to the resolution of multiple related symptoms.
Surgical Care
Individuals experiencing advanced and long-standing dysphagia typically necessitate mechanical dilation as part of their treatment. Commonly employed methods for dilation encompass endoscopic balloon dilatation or the use of Savary-Gilliard dilators. The term therapeutic endoscopy refers to the intentional disruption of the esophageal web, often resulting in a minor amount of fresh blood appearing on the web site.
While the esophageal web can sometimes be broken by the mere insertion of an endoscope into the esophagus, more challenging cases might require the use of a bougie, which has demonstrated efficacy. In most instances, employing a solitary large dilator proves adequate and frequently yields superior results compared to a progressive dilation approach conducted sequentially.
Dietary Modification
In addition to iron supplementation, dietary adjustments can effectively address the needs of mildly symptomatic patients. It is recommended that patients adopt the practice of eating slowly and thoroughly chewing their food. Particular attention should be given to preparing solids, which should be sliced into smaller portions, mainly when dealing with meats. Surgical intervention is a rare consideration, primarily reserved for cases in which dilation proves ineffective in managing esophageal webs, or when these webs are connected with Zenker diverticulum.
medtigo
Plummer-Vinson Syndrome
Updated :
August 26, 2023
Plummer-Vinson syndrome (PVS), or Paterson-Brown-Kelly syndrome, is a rare medical condition primarily affecting the upper digestive tract. It is characterized by symptoms, including dysphagia, iron-deficiency anemia, and thin, membranous tissue called esophageal webs within the throat. These esophageal webs can narrow the upper esophagus and cause further difficulty in swallowing.
The exact cause of Plummer-Vinson syndrome is not fully understood. However, it is thought to result from various factors, including nutritional deficiencies, genetic predisposition, and potential autoimmune processes. The syndrome is more commonly observed in middle-aged women, although cases have been reported in individuals of various ages and genders.
A significant concern associated with Plummer-Vinson syndrome is its connection to an increased risk of developing squamous cell carcinoma in the pharynx and proximal esophagus. While the exact link between PVS and cancer is not fully understood, the chronic inflammation and irritation caused by the condition’s features, including the esophageal webs and nutritional deficiencies, are believed to contribute to the heightened cancer risk.
Plummer-Vinson syndrome is a relatively rare condition, and its exact prevalence is not well-defined. However, it is generally considered to be uncommon. PVS predominantly affects women, particularly those in middle age, although cases have been reported in individuals of various ages and genders. The syndrome’s higher incidence in women suggests a potential hormonal or gender-related predisposition, but the exact mechanisms are not fully understood.
Plummer-Vinson syndrome exhibited a higher occurrence in the first half of the 20th century, particularly among middle-aged women of Scandinavian origin. The prevalence of this syndrome experienced a rapid decline in the latter half of the 20th century, attributed to boosted nutritional awareness, notably the widespread enrichment of flour with iron. PVS has primarily been documented within the Caucasian demographic, with a predominant occurrence in women.
In earlier investigations in Scandinavian populations, as much as 90% of individuals afflicted with PVS were reported to be women. Typically, the syndrome is diagnosed in the age range of 40 to 70 years, although a limited number of cases have been identified in children. Geographically, Plummer-Vinson syndrome has been reported in various parts of the world, although it may be more prevalent in certain regions. It has been associated with nutritional deficiencies, particularly iron deficiency, which can be influenced by factors such as dietary habits and socioeconomic status.
As access to healthcare and nutrition improves, the prevalence of PVS may decrease, given that one of its underlying causes is iron-deficiency anemia. Because Plummer-Vinson syndrome is rare and often goes undiagnosed or misdiagnosed due to its varied and non-specific symptoms, it’s challenging to provide precise epidemiological data. Medical literature and databases may contain varying estimates of its prevalence, and the condition might be underreported.
Iron deficiency anemia is a hallmark of PVS. Chronic blood loss from the esophageal webs, which can cause small amounts of bleeding, contributes to this anemia. The esophageal webs themselves may result from long-term iron and other nutrient deficiencies. Iron is essential for properly functioning hemoglobin, the molecule responsible for transporting oxygen in the blood. Inadequate iron levels can lead to anemia, resulting in fatigue, weakness, and other related symptoms.
PVS appears to have a gender and age predisposition, which is more common in middle-aged women. This suggests potential hormonal or genetic influences on the development of the syndrome. However, specific genes associated with PVS have not been definitively identified. PVS has been associated with various autoimmune and immune-mediated disorders, such as celiac disease, Crohn’s disease, rheumatoid arthritis, and thyroid diseases.
This has led to speculation about immune dysregulation playing a role in the development of PVS. The immune system’s involvement in chronic inflammation and tissue damage could contribute to the formation of esophageal webs and other characteristic features of the syndrome.
Even after a century since the initial reports of cases, the exact cause of Plummer-Vinson syndrome’s (PVS) development remains elusive. Various theories have been proposed to explain its origin, including nutritional and iron deficiencies, genetic predisposition, and potential autoimmunity. However, the supporting evidence for these hypotheses is generally limited, with the exception of iron deficiency, which consistently emerges as a significant factor.
This is partly due to studies indicating that dysphagia tends to improve with iron supplementation, while iron deficiency is thought to contribute to mucositis, possibly leading to the formation of esophageal webs. Given that individuals with PVS may experience malnutrition, some researchers have posited vitamin B deficiency as a potential causative factor. Furthermore, Plummer-Vinson syndrome has been associated with celiac disease, Crohn’s disease, rheumatoid arthritis, and thyroid disorders.
This association hypothesizes that immune dysregulation might be involved in the syndrome’s development, although this aspect remains unproven. In all instances, it is crucial to investigate the underlying reasons for the iron deficiency seen in PVS patients. This includes exploring potential causes such as gastrointestinal bleeding and conditions like celiac disease. Despite ongoing research efforts, the precise cause of Plummer-Vinson syndrome remains unknown, necessitating further exploration to unravel its complex pathogenesis.
Clinical History
Individuals with Plummer-Vinson syndrome often present with a history of chronic symptoms related to their upper digestive tract and overall health. These symptoms may develop gradually and worsen over time. Dysphagia is a hallmark symptom of PVS. Individuals may complain of a sensation of food sticking in the throat or chest while eating, which can lead to discomfort and reduced food intake. Iron deficiency anemia is a common consequence of PVS due to chronic blood loss from the esophageal webs.
Anemic symptoms might include fatigue, weakness, pale skin, and shortness of breath. The onset and duration of Plummer-Vinson syndrome can vary among individuals. Generally, the syndrome develops over time, and symptoms worsen gradually. The age at onset can vary, but it is typically observed in individuals between the ages of 40 and 70. However, cases have been reported in people of different ages, including children, although these are rare. Without intervention, the symptoms of PVS can persist and potentially worsen over an extended period.
Physical Examination
Anemia, particularly iron deficiency anemia, is a key component of PVS. This can lead to a pale appearance of the skin and mucous membranes. Also known as spoon nails, koilonychia refers to nails that are concave and have a scooped-out appearance. Cracks and inflammation at the corners of the mouth can indicate nutritional deficiencies, including iron deficiency.
Anemia can lead to general weakness and fatigue. Patients might appear tired and have reduced energy levels. Anemia can result in tachycardia as the heart tries to compensate for the decreased oxygen-carrying capacity of the blood. Splenomegaly might be observed in severe PVS cases due to chronic anemia’s effects on blood cells and the circulatory system. However, this finding is rare.
Differential Diagnoses
Achalasia
Gastroesophageal reflux disease
Hypopharyngeal bar
Scleroderma
Treatment
(Administration of pharmaceutical agent section)
Iron Supplementation
The medical approach to managing Plummer-Vinson syndrome involves the administration of iron supplements. As part of the management process, healthcare professionals typically investigate the potential presence of occult or overt blood loss, rule out underlying malignancies, and assess for iron malabsorption. The administration of iron replacement therapy is crucial for addressing anemia and resolving the various manifestations associated with iron deficiency.
While the necessity for ongoing iron replacement remains uncertain beyond anemia correction, ensuring proper anemia management is vital. Usually, a dose of elemental iron ranging from 150 to 200 mg is required to effectively rectify iron deficiency anemia. Notably, dysphagia, a prevalent symptom in many patients, often eases with the sole intervention of iron supplementation. This approach focuses on addressing the core nutritional deficiency underlying Plummer-Vinson syndrome and can lead to the resolution of multiple related symptoms.
Surgical Care
Individuals experiencing advanced and long-standing dysphagia typically necessitate mechanical dilation as part of their treatment. Commonly employed methods for dilation encompass endoscopic balloon dilatation or the use of Savary-Gilliard dilators. The term therapeutic endoscopy refers to the intentional disruption of the esophageal web, often resulting in a minor amount of fresh blood appearing on the web site.
While the esophageal web can sometimes be broken by the mere insertion of an endoscope into the esophagus, more challenging cases might require the use of a bougie, which has demonstrated efficacy. In most instances, employing a solitary large dilator proves adequate and frequently yields superior results compared to a progressive dilation approach conducted sequentially.
Dietary Modification
In addition to iron supplementation, dietary adjustments can effectively address the needs of mildly symptomatic patients. It is recommended that patients adopt the practice of eating slowly and thoroughly chewing their food. Particular attention should be given to preparing solids, which should be sliced into smaller portions, mainly when dealing with meats. Surgical intervention is a rare consideration, primarily reserved for cases in which dilation proves ineffective in managing esophageal webs, or when these webs are connected with Zenker diverticulum.
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