Where's the ulcer? Spontaneous bleeding from Zenker's diverticulum.

An 89-year-old man with a history of coronary artery disease status post coronary artery bypass grafting and atrial fibrillation on aspirin and warfarin, presented to the emergency department with a symptom of haemoptysis. He reported a history of dysphagia for 3 months prior to presentation, but had yet to seek medical attention. On presentation, he was hypotensive and tachycardic with a haemoglobin of 6.6 g/dL and an International Normalised Ratio (INR) of 3.9. Esophagogastroduodenoscopy was performed and showed active bleeding from Zenker's diverticulum. The patient's INR was reversed with fresh frozen plasma and his anaemia was treated with packed red blood cells. The bleeding stopped after reversal of his INR. A barium swallow confirmed a 9 cm Zenker's diverticulum. The patient had a diverticulectomy and cricopharyngeal myotomy. Histology showed mild chronic inflammation of the mucosa, but no ulceration. The patient was discharged without any further bleeding episodes. 2014 BMJ Publishing Group Ltd.