Acta Medica Indonesiana

Patients with Systemic Lupus Erythematosus with Anxiety or Depression: Clinical Characteristics, Food Intake, and Gut Microbiota Profile

2025-06-11T05:51:51+00:00

Background: Depression and anxiety are prevalent among patients with systemic lupus erythematosus (SLE),
and gut microbiota may be a contributing factor. This study aimed to investigate the clinical characteristics,
food intake, and gut microbiota profiles of SLE patients with anxiety or depression. Methods: An analysis of
secondary data was conducted. The primary study was conducted at Cipto Mangunkusumo Hospital, Jakarta,
Indonesia, in 2017–2018. The inclusion criteria were: a diagnosis of SLE, age 18‒60 years, and gastrointestinal
symptoms. The data collected included clinical data, food intake, anxiety and depression scores, SLE disease
activity, and stool samples. Sequencing of the 16S rRNA gene was performed to profile the gut microbiota using
DNA was extracted from the stool samples. Results: After excluding those with incomplete data, 41 patients were
analyzed. Among the subjects, 53.66% and 14.63% had anxiety and depression, respectively. SLE patients with
anxiety were significantly more likely to harbor Bacteroides compared to those without anxiety (33.45% vs.
9.78%; p=0.02) and had lower levels of complement C3 (78.72 vs. 100.85 mg/dL; p=0.03). SLE patients with
anxiety or depression had significantly lower fat intake compared to those without these conditions (38.78 vs.
48.43 g/day; p=0.04, and 31.48 vs. 45.27 g/day; p=0.04). A significant correlation was observed between the
proportion of Bacteroides and SLE disease activity (p=0.02). Conclusion: SLE patients with anxiety showed
a significantly higher proportion of Bacteroides and a lower C3 level compared to those without anxiety. Fat
intake was significantly lower among SLE patients with anxiety or depression compared to those without either
condition

Factors Associated with Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) Related Mortality at Dr. Sardjito Hospital in Indonesia

2025-03-10T06:06:29+00:00

Background: By 2019, the human immunodeficiency virus (HIV) had infected approximately 3.8 million people in Southeast Asia and caused 120,000 deaths. In Indonesia, despite periodic fluctuations, the incidence of HIV/AIDS continues to rise annually. Although antiretroviral therapy (ART) has substantially extended the lives of people living with HIV/AIDS (PLWHA), various risk factors continue to influence treatment outcomes. This study aimed to identify the risk factors significantly associated with mortality among PLWHA undergoing ART therapy at RSUP Dr. Sardjito Hospital, Yogyakarta, Indonesia. Methods: In a retrospective cohort design, we reviewed sociodemographic and clinical data of all adult PLWHA (aged ≥18 years) who initiated ARV therapy at RSUP Dr. Sardjito Hospital between January 2008 and December 2021. Patients with incomplete baseline data or those referred from other facilities were excluded. The final cohort was categorized into surviving and deceased groups. Univariate and multivariate logistic regression analyses were conducted to determine the factors linked to mortality, and survival probabilities were estimated using Kaplan–Meier curves. Results: Out of 1,591 patients included in the study, 199 died during the follow-up period. Univariate analysis revealed that age over 45 years, tuberculosis status, low CD4+ count, occupation, and advanced clinical stage of HIV/AIDS were significantly associated with mortality. Multivariate analysis further demonstrated that low CD4+ count, employment status, and, most notably, advanced clinical stage (stages 3 and 4) were independent predictors of death. The survival probabilities at 1 and 5 years were 89% and 87%, respectively. Conclusion: Occupation, CD4+ count, and clinical stage critically influence mortality in PLWHA on ART therapy, with advanced clinical stage being the most significant. Early diagnosis and prompt ART initiation are essential to enhance survival.

Atherogenic Lipoprotein Profile in First-Degree Relatives of Individuals with Type 2 Diabetes Mellitus

2025-05-06T04:56:59+00:00

Background: First-degree relatives (FDR) of individuals with type 2 diabetes mellitus (T2DM) are at higher risk of developing early metabolic disturbances, particularly insulin resistance and lipid metabolism abnormalities. These issues contribute to a greater predisposition to cardiovascular disease compared to the general population. Despite the significant contribution, there is limited information on the relationship between atherogenic lipoproteins and normotensive, normoglycemic young FDR in Indonesia. Therefore, this study aimed to evaluate the correlation between small dense low-density lipoprotein (sdLDL) levels and HOMA-IR in FDR with T2DM, as well as assess variation in sdLDL levels within FDR and non-FDR groups. Methods: This cross-sectional study analyzed secondary data from the Metabolic Endocrine and Diabetes Division of the Internal Medicine Department, Faculty of Medicine, Universitas Indonesia, and Cipto Mangunkusumo Hospital. The primary study, titled “Early Cardio-Metabolic Disorders in the First-Degree Relative Population of Type 2 Diabetes Mellitus,” was expanded to include sdLDL measurements. Bivariate analysis and correlation tests were used to explore the relationship between sdLDL and HOMA-IR. Results: The experiment included 125 subjects, consisting of 62 FDR and 63 non-FDR. Based on the results, sdLDL levels were significantly higher in the FDR group compared to the non-FDR group (31.42 (IQR 20.1-41.39) vs 21.05 (IQR 12.18-26.13) mg/dL, p<0.0001). However, no significant correlation was observed between sdLDL levels and HOMA-IR in the FDR group (r=0.059, p=0.649). Conclusion: This study showed a significant difference in sdLDL levels between FDR and non-FDR of T2DM patients. However, no correlation was found between sdLDL and HOMA-IR in the FDR group.

Characteristics and Care Quality of Patients with Type 2 Diabetes in Indonesia: A Study of DISCOVER CaReMe Registry Program

2025-07-23T05:21:46+00:00

Background: Type 2 diabetes mellitus (T2DM) is considered one of the top 3 causes of death in Indonesia. However, the current scenario regarding the management of T2DM in Indonesia remains unclear. Thus, the present study aimed to describe the baseline characteristics, treatment types, and quality of care indicators in T2DM patients under the DISCOVER CaReMe Registry program. Methods: DISCOVER CaReMe Registry program is a multi-centre, prospective, and observational study conducted over 3 years from 2018 to 2021. The data were collected from five different sites across Indonesia. Results: A total of 539 patients with a mean age of 58.98 ± 9.76 were enrolled in the study. Among them, 62% (334/539) of patients were females. Further, the mean glycated haemoglobin (HbA1c) levels were 8.54 ± 2.88%, which was much higher than the American Diabetes Association (ADA) recommended target of 7%. Overall, 69% of the patients had HbA1c levels of >7%. First-line treatment in patients was mostly metformin (26%). As per the quality-of-care indicators, 72.2% of patients use glucose monitoring equipment and receive education about diabetes treatment and management. Furthermore, the knowledge of T2DM among patients was assessed in over 85% of cases, and misconceptions about the condition were clarified by healthcare professionals (HCPs). HCP advised a “diabetic diet” to 69.4% of patients. Conclusion: Despite a good knowledge and quality of care indices in patients with T2DM, the proportion of patients with HbA1c levels of >7% is still higher. There is an urgent need for diabetic management programs to prevent such complications in the Indonesian population.

Application of Machine Learning on Health Examination Data for Predicting the Decrease of Bone Mineral Densit

2025-01-24T07:31:04+00:00

Background: Early detection and preventive measures for reduced bone density can greatly improve patients' quality of life and reduce economic burdens. This study aimed to develop machine learning algorithms that can accurately predict the risk of bone mineral density loss. Methods: The study included participants aged 40 years and older who underwent health evaluations at an affiliated institution from January 2022 to January 2024. Five machine learning algorithms were used to predict the risk of osteoporosis: k-nearest neighbor (KNN), random forest (RF), support vector machine (SVM), artificial neural network (ANN), and logistic regression (LR). The performances were evaluated based on accuracy, sensitivity, specificity, and area under the receiver operating characteristic curve (AUROC). Results: This study included 11132 patients, of whom 3568 had decreased bone density. The initial dataset contains 17 variables. After the data screening, 13 variables were included in the machine learning model. The AUROC for ANN, KNN, LR, RF, and SVM were 0.882, 0.906, 0.684, 0.918, and 0.896 for males, and 0.881, 0.843, 0.784, 0.922, and 0.872 for females, respectively. The accuracies of ANN, KNN, LR, RF, and SVM were 0.83, 0.86, 0.75, 0.88, 0.82 for males, and 0.81, 0.77, 0.74, 0.85, 0.79 for females. Conclusion: In this study, we developed five machine learning models to predict bone density reduction accurately. The RF model performed best in both male and female populations, with the highest AUROC. Application of machine learning models in clinical settings can help improve the prevention, detection, and early treatment of bone density reduction.

Performance of Red Cell Distribution Width-to-Platelet Ratio as a Screening Tool of Liver Fibrosis Based on Transient Elastography in Chronic Hepatitis B Infection

2025-07-15T05:55:00+00:00

Background: Identifying liver fibrosis is crucial for initiating antiviral therapy for hepatitis B infection. Liver biopsy is the gold standard for assessing the degree of fibrosis. However, a liver biopsy is an invasive procedure that carries some risks. This study aimed to evaluate the diagnostic capabilities of the red cell distribution width-to-platelet ratio (RPR) and compare its efficacy for determining the degree of fibrosis in patients with chronic hepatitis B infection with that of the aspartate aminotransferase-to-platelet ratio index (APRI) and the Fibrosis-4 index (FIB-4). Methods: This was a retrospective study conducted on patients with chronic hepatitis B infection who had transient elastography results at the Gastroenterology Hepatology Clinic, Dr. Hasan Sadikin General Hospital, Bandung, between January and December 2024. Statistical analysis was performed using receiver operating characteristic curves to determine the diagnostic values and cutoff points of the RPR, APRI, and FIB-4 to detect liver fibrosis based on Transient Elastography in patients with Chronic Hepatitis B infection. Results: A total of 114 patients with chronic hepatitis B infection were included in this study (42 with significant fibrosis and 72 with nonsignificant fibrosis). The area under the curve (AUC) of the RPR was 0.873 (p < 0.001) with a cutoff point of >0.0538, whereas the AUCs of the APRI and FIB-4 were 0.833 (p < 0.001) and 0.746 (p < 0.001), respectively. Conclusion: The RPR has a higher diagnostic performance than the APRI and is superior to the FIB-4 in assessing the degree of fibrosis in patients with chronic hepatitis B infection. The RPR is a simple and cost-effective test and has the potential to be a screening tool for patients with hepatitis B infection.

Correlation of Serum FT4 with Serum Uric Acid and Comparison of Uric Acid in Subjects with and without Atrial Fibrillation in Graves’ Disease: A Cross-Sectional Study

2025-05-06T04:33:38+00:00

Background: Cardiovascular diseases increase the mortality risk in Graves’ disease (GD) patients. Atrial fibrillation (AF) is one of the most prevalent cardiovascular diseases in GD. Hyperthyroidism that occurs in GD may increase uric acid levels, while uric acid levels can also increase the risk of AF in the general population. This study is designed to observe the correlation between free T4 (FT4) and uric acid, and compare the levels of uric acid in subjects with and without AF in GD. Methods: A cross-sectional study was conducted, including GD patients who met research criteria in Dr. Cipto Mangunkusumo Hospital during 2024. We performed history taking, physical examination, laboratory examination, and electrocardiogram for each subject. Data was analyzed using Pearson or Spearman correlation, and bivariate analysis to evaluate the comparison of uric acid in subjects with and without AF. Results: We included 74 subjects, with an average age of 41 years, mostly female (86.5%), and 62.2% had normal FT4 levels. AF occurred only in 4.1% subjects. Mean of uric acid is 4.71 ± 1.2 mg/dl, which is within the normal range. No correlation was found between FT4 and uric acid (r = 0.076; p = 0.520), including after adjustment with subgroup analysis based on thyroid status, gender, and diabetes mellitus. Mean of uric acid is not statistically different between subjects with and without AF (4.9 ± 1.01 mg/dl vs 4.7 ± 1.2 mg/dl; p = 0.785). Conclusion: No significant correlation was found between FT4 and uric acid. Mean of uric acid is not statistically different between subjects with and without AF.

Association Between Leptin and Adiponectin Levels and Sarcopenia in Non-Geriatric Type 2 Diabetes Mellitus Patients

2024-12-23T05:12:07+00:00

Background: Type 2 Diabetes Mellitus (T2DM) in young adults is associated with an increased risk of early sarcopenia due to insulin resistance and inflammation. This insulin resistance and inflammation can be influenced by leptin and adiponectin, which are key adipocytokines produced by adipose cells. However, no studies have examined the relationship between leptin, adiponectin levels, and sarcopenia in T2DM patients under 60 years old. This study aimed to investigate the relationship between leptin, adiponectin levels, and Leptin-to-Adiponectin ratio (LAR) with sarcopenia in non-geriatric T2DM patients. Methods: This cross-sectional study was conducted from January 2021 to April 2022. The subjects consisted of T2DM patients aged 18-59 years at Cipto Mangunkusumo Hospital, Jakarta, Indonesia. Baseline data were sourced from a primary study, while stored serum samples were analyzed for leptin and adiponectin using ELISA. Leptin and adiponectin differences were assessed statistically using the Mann-Whitney U test, and the Kruskal-Wallis test was used for additional analysis. Results: Among 97 subjects, 4 (4.1%) had sarcopenia, while 34 out of 93 non-sarcopenic subjects belonged to the possible sarcopenia category. Bivariate analysis results showed significant differences between leptin levels (p=0.005) and the Leptin-to-Adiponectin Ratio (LAR) (p=0.003) with sarcopenia in non-geriatric T2DM patients. Meanwhile, adiponectin levels (p=0.799) did not show statistical differences. Further analysis was conducted among three groups, namely sarcopenia, possible sarcopenia, and non-sarcopenia. The result showed statistically significant differences in leptin and LAR levels between sarcopenia and possible sarcopenia (leptin p=0.004; LAR p=0.007) as well as sarcopenia and non-sarcopenia (leptin p=0.038; LAR p=0.011). Conclusion: Leptin levels and LAR were associated with sarcopenia in a non-geriatric T2DM population.

Atherogenic Dyslipidaemia in Diabetes: Burden and Challenges

2025-10-02T05:15:06+00:00

Atherogenic dyslipidemia is a lipid disorder characterized by high triglyceride (triglyceride-rich lipoprotein) levels, reduced HDL-C levels, and an abundance of small dense LDL (sdLDL) particles. This condition is frequently associated with diseases or states that involve insulin resistance and inflammation, such as obesity, metabolic syndrome, and type 2 diabetes. Atherogenic dyslipidemia/lipoprotein is linked to a heightened risk of cardiovascular disease. The presence of numerous sdLDL particles and remnant lipoproteins are critical in the development and buildup of plaque in atherosclerosis. Elevated triglyceride levels can also promote inflammation and thrombosis within the arterial walls. In addition to lifestyle modifications, cholesterol-lowering drugs—whether used alone or in combination—are often prescribed for the prevention or management of atherosclerotic cardiovascular disease (ASCVD), including statins, ezetimibe, bempedoic acid, and PCSK9 inhibitors.

Telemedicine-assisted Directly Observed Therapy (DOTS) for Tuberculosis: An Evidence-based Case Report

2024-12-16T04:47:14+00:00

Background: Tuberculosis is a high-burden infectious disease requiring long-term treatment. Compliance is the key to cure; however, directly observed therapy (DOTS) is not always feasible. Telemedicine use in DOTS offers improved accessibility; however, its effectiveness has not been established. We aimed to investigate the effectiveness of telemedicine-based DOTS on treatment compliance in patients with tuberculosis. Methods: Databases including MEDLINE, Scopus, EMBASE, PubMed, and Cochrane were searched for studies implementing telemedicine-based DOTS until November 2nd, 2023. Studies were appraised for validity, importance, and applicability using the Oxford Centre of Evidence-Based Medicine tool, and the outcomes were graded based on their levels of evidence (LOE). Results: Our search yielded six systematic reviews. Telemedicine-based DOTS yielded favourable effects in improving adherence (LOE: I), treatment completion (LOE: II-III), and cure rates (LOE: II-III). Other outcomes, in terms of bacteriological resolution (LOE: II) and mortality (LOE: IV), were estimated to be non-inferior to those of DOTS. In terms of the telemedicine mode, the VDOTS yielded the highest LOE in improving adherence (LOE: I), followed by short messaging services (LOE: III) and medication monitors (LOE: III), which yielded similar effects. Results for phone reminders were contradictory, with the highest evidence suggesting that it might be ineffective for treatment completion (LOE: I-III) but may increase the cure rate (LOE: III). Conclusion: Telemedicine-based DOTS may improve adherence, treatment completion, and cure rate, and is non-inferior in terms of bacteriological resolution and mortality. Telemedicine-based DOTS can be considered for implementation; however, further high-quality studies in limited-resource settings are needed to strengthen the evidence.

The Use of Secretome and Exosomes in Cardiovascular Diseases

2025-03-11T05:02:08+00:00

Cardiovascular diseases (CVDs) remain a leading cause of morbidity and mortality worldwide. Recent advancements in regenerative medicine have unveiled the promising roles of secretome and exosomes in the treatment of CVDs. In this article, we aim to understand the roles of secretome and exosomes in the cardiovascular system, both in physiological and pathological conditions, and explore the broad applications of secretome and exosomes in mitigating CVD progression. Secretome and exosomes, which play crucial roles in intercellular communication, tissue repair, and immunomodulation, have shown potential in reducing cardiovascular disease progression by inhibiting inflammation, promoting blood vessel growth, and regulating biological mechanisms. Further research is needed to maximize their use in advanced cardiovascular therapy.

Hepatitis B Virus Reactivation Superimposed Hepatitis A Co-Infection Leading to Acute on Chronic Liver Failure: A Case Report and Literature Review

2024-11-17T08:25:24+00:00

Acute-on-chronic liver failure (ACLF) is a severe condition with an incidence rate of 5.7 cases per 1,000 person-years. A primary trigger for ACLF is hepatitis B reactivation, which is responsible for 40-60% of cases. Co-infection with hepatitis A can also contribute to its occurrence.
This study presents the case of a 58-year-old male patient with a history of hepatitis B virus (HBV)-related cirrhosis, presenting with symptoms including confusion, disorientation, worsening jaundice, abdominal discomfort, nausea, vomiting, loss of appetite, malaise, muscle pain, and fever. Despite regular treatment for HBV, the patient’s condition deteriorated over 14 days. He had no history of hypertension, diabetes, autoimmune diseases, alcohol consumption, or smoking. On examination, the patient exhibited grade 2 hepatic encephalopathy, severe jaundice, ascites, and lower limb edema. Laboratory results revealed elevated liver enzymes, increased bilirubin levels, and decreased albumin. Subsequent testing confirmed acute hepatitis A infection and a significant hepatitis B viral load.
The report highlights that reactivation of Chronic Hepatitis B, accompanied by co-infection with hepatitis A, played a critical role in inducing inflammation and worsening the ACLF condition.

Complete Atrioventricular (AV) Block as a Cardiac Complication of Rheumatoid Arthritis: A Rare Case Report

2024-04-29T05:45:38+00:00

Atrioventricular block (AVB) is a rare complication of rheumatoid arthritis (RA). Complete AVB in people with RA significantly increases cardiovascular morbidity and doubles the mortality risk. We report on a 48-year-old woman presenting with dyspnea and peripheral edema, with symptoms of polyarthritis for 3 years. Physical findings included bradycardia, bilateral rales, and finger deformities consistent with RA. Electrocardiography featured complete AVB, and a thoracic computed tomography scan showed a mosaic appearance with fibrosis, bronchiectasis, and partial atelectasis of the lungs. Further tests showed elevated levels of C-reactive protein, rheumatoid factor, and several inflammatory cytokines. Transient followed by permanent pacemaker placement was performed along with pharmacological treatments, including intravenous (IV) methylprednisolone pulse therapy and IV tocilizumab. Cardiac involvement in RA usually takes the form of pericardial effusion, heart failure, myocarditis, and coronary artery disease. Complete AVB is a rare but important extra-articular involvement in RA that warrants early recognition and treatment with a pacemaker, anti-inflammatory drugs, and disease-modifying antirheumatic drugs.

Buried in Trapped Air: Tension Pneumothorax, Massive Subcutaneous Emphysema and the Battle for Airway Control

2025-04-14T08:37:00+00:00

ABSTRACT:

Background: Tension pneumothorax (TP) is defined as a pneumothorax in which the pressure of intrapleural air exceeds atmospheric pressure, producing adverse effects, including contralateral mediastinal shift associated with cardiovascular collapse, due to reduced venous return (because of compression of the SVC and IVC ) and hypoxia. Usually, patients with TP present to the Emergency Department with vague pleuritic chest pain and shortness of breath, but being considered a red flag it should be diagnosed during the primary assessment and managed promptly with large bore needle decompression followed by chest tube insertion. Presence of extensive subcutaneous emphysema (SCE) can further aggravate the respiratory distress and make the airway management even more challenging in the ER. Situation can become even worse when such a patient needs cardiopulmonary resuscitation on arrival.

Case report: We report an unusual case of a 55 years old man, who presented in the ER with history of sudden onset respiratory distress while taking bath. Patient was brought to the ER in a state of gasping, hypoxia and shock . Needle decompression of the pneumothoraces was not sufficient as he also had extensive subcutaneous emphysema which resulted in cardiac arrest. The CPR and the airway management extremely were practically difficult. He was finally tracheostomised in the ER and accompanied by bilateral chest-tube thoracotomy. He was discharged for home after pleurodesis without any neurological deficit.

Conclusion: Primary spontaneous pneumothorax is an uncommon condition but can rarely end up in tension pneumothorax and accompanying subcutaneous emphysema can make the management further challenging. Airway skills of the ER team are important in saving such patients’ lives.

Hyperbilirubinemia with Unusual Dermatologic Signs: A Diagnostic Puzzle

2025-03-06T07:42:58+00:00

Jaundice, characterized by yellow discoloration of the skin, mucous membranes, and sclera, results from hyperbilirubinemia and is uncommon in adults. Its occurrence often signals serious underlying conditions. Hyperbilirubinemia may also present with cutaneous manifestations, including xerosis, hyperpigmented plaques, and erythematous rashes. A 47-year-old woman presented with hyperbilirubinemia, transaminitis, and cutaneous manifestations, including hyperpigmented plaques on the face, erythematous rashes on the hands and feet, and yellowish discoloration of the skin. Despite extensive evaluation, including viral hepatitis screening, autoimmune markers, and imaging, a definitive diagnosis remained elusive. The clinical features and laboratory findings suggested Primary Biliary Cholangitis (PBC) as the most likely diagnosis, although further confirmation through advanced serological testing and liver biopsy was needed. Treatment with ursodeoxycholic acid (UDCA) and high-dose oral methylprednisolone showed clinical improvement but persisted in transaminitis with a normal ultrasonographic appearance. This case emphasizes the importance of recognizing cutaneous signs in systemic diseases and the need for a comprehensive diagnostic approach in resource-limited settings.

p.Gly693Arg Homozygote Mutation in Dubin-Johnson Syndrome with Atypical Liver Biopsy due to Reactivation of Hepatitis B Concomitant with Persistent Loss of Kidney Function

2025-01-14T05:31:30+00:00

Dubin-Johnson syndrome is a rare genetic disease that causes impaired transport of bilirubin. In most cases, there will be no symptoms. However, some people might develop jaundice due to certain conditions. In this case, we would like to present a 54-year-old male patient with Dubin-Johnson syndrome confirmed through genetic analysis showing homozygote mutation of p.Gly693Arg, with no apparent bile deposition in liver biopsy and reactivation of hepatitis B. The Patient had no symptoms since birth and was recently found to have an increased level of direct bilirubin. Further inspection showed a familial pattern of the disease. This is a unique case of homozygote mutation with p.Gly693Arg with atypical presentation of liver biopsy and reactivation of hepatitis B with no clinical manifestation.

The Role of Psychotherapy in the Management of Inflammatory Bowel Disease

2025-05-17T05:21:36+00:00

Inflammatory bowel disease (IBD), consisting of ulcerative colitis (UC) and Crohn’s disease (CD), represents one of the debilitating chronic gastrointestinal diseases that affects the physical and psychological aspects of patients, leading to increased morbidity and mortality and affecting patients' quality of life. There is an increased prevalence of depressive disorders and anxiety among IBD patients, with the gut-brain axis as the proposed underlying mechanism. Treatment of psychological issues among patients with IBD enhances long-term management outcomes. Therefore, we provide a comprehensive review of epidemiology, pathomechanism, diagnosis, and treatment modality of psychological issues frequently found among IBD patients.

Per-oral Endoscopic Myotomy (Z-POEM): An Effective Treatment for Zenker's Diverticulum with Long-Term Results

2025-01-17T05:10:16+00:00

Zenker's diverticulum (ZD) arises from impaired cricopharyngeal (CP) muscle distensibility during deglutition (swallowing), leading to a clinical presentation characterised by dysphagia, regurgitation, aspiration, cough, and potential weight loss. The definitive treatment for ZD is a CP myotomy. Traditionally, open surgical approaches (transcervical diverticulectomy, diverticulopexy, or diverticular inversion) with or without concomitant CP myotomy and rigid endoscopic techniques utilizing stapling or CO2 laser therapy have been employed. However, these interventions are often associated with significant morbidity and mortality, particularly in the elderly and comorbid ZD patient population.

The advent of flexible endoscopic ZD treatment has revolutionized the therapeutic landscape, rapidly becoming the preferred first-line modality for the management of small to moderate-sized diverticula. The past decade has witnessed the emergence of a multitude of novel techniques within the realm of flexible endoscopic ZD treatment.

In this medical illustration, we report a woman, 64-years-old with Zenker’s diverticulum treated with Z-POEM. She came to our clinic with dysphagia and regurgitation for 6 months prior. Diagnostic gastroscopy showed ZD of 3 cm, located 18 cm from incisors with a thick septal muscle. A triangle-shaped knife created a 2-cm mucosal incision, and submucosal tunneling was made by spray coagulation. The gastroscope was advanced through the submucosal space of the esophageal lumen and the diverticulum site until the bottom of the diverticulum. The septal muscle was completely cut, immediately allowing the gastroscope to pass through easily, and the mucosal defect was closed with hemoclips. Six months after the treatment, the patient no longer experiences dysphagia and regurgitation.

Z-POEM offers a precise approach to treating Zenker's diverticulum by providing a complete visualization of the entire septal muscle. This comprehensive view minimizes the risk of incomplete myotomy, ensuring a more effective treatment.