supraphrenic esophageal diverticulum
Introduction
Introduction to the upper esophageal diverticulum Clinically, the diverticulum that appears within 10 cm of the distal end of the esophagus is called the epiphrenicdiverticulaoftheesophagus. The vast majority of the upper sacral diverticulum is a bulging diverticulum, which is a weak or defective area of the esophageal mucosal smooth muscle layer. Formed by protruding or protruding. The upper esophageal diverticulum is much less common than the zenker diverticulum, which gradually forms from small to large, often associated with dysregulation of esophageal motor function. Moreover, almost all patients with hiatal hernia and gastroesophageal reflux are considered to be acquired diseases and are also associated with congenital factors. basic knowledge The proportion of illness: 0.004% Susceptible people: no specific population Mode of infection: non-infectious Complications: diffuse esophageal fistula, achalasia, esophageal hiatus hernia
Cause
Clinical esophageal diverticulum
(1) Causes of the disease
Most of the upper esophageal diverticulum occurs on the right side of the thoracic esophagus. The mucosa protrudes or sputum between the muscle fibers. It is more common in the elderly. Most of the upper esophageal diverticulum is acquired, but congenital can also occur in this area. In the diverticulum, most of the patients with symptomatic supracondylar esophageal diverticulum have esophageal or mechanical infarction, which increases the pressure in the esophageal lumen. The prominent mucosa in the weak part of the esophageal muscle layer is similar to the development of the pharyngeal esophageal diverticulum.
Debas et al (1980) performed radiology, endoscopy, and manometry on 65 patients with suprapubic esophageal diverticulum. Found 50 (77%) abnormalities in esophageal motor function, including diffuse fistula, achalasia, or lower esophagus. Sphincter hypercontraction, 15 cases (23%) with normal motor function, 13 cases with hiatal hernia, 5 cases with distal esophageal stenosis, indicating that before surgery, we should thoroughly understand the changes of each case, whether there is function at the distal end of the esophagus Sexual or organic obstruction.
(two) pathogenesis
The upper esophageal diverticulum is gradually formed from small to large, often associated with dysfunction of esophageal motor function, and almost all patients have hiatal hernia and gastroesophageal reflux. Therefore, many authors believe that the upper esophageal diverticulum is acquired. The disease is also related to congenital factors.
The upper esophageal diverticulum bulges from the right posterior wall of the esophagus and protrudes to the right thoracic cavity. Some people speculate that the reason may be that the thoracic aorta and the heart restrict the expansion of the diverticulum to the left side, and the upper esophageal diverticulum can also protrude to the left side. The site can also be slightly higher, and occasionally there are multiple diverticulum. These phenomena indicate that the cause of the esophageal diverticulum is different from that of the pharyngeal esophageal diverticulum.
Pathologically, the esophageal diverticulum wall has only mucosa and submucosa. There are only scattered muscle fibers or no muscle fiber tissue at all. It rarely causes symptoms or complications, and is often caused by other diseases of the esophagus such as hiatal hernia, diffuse esophageal fistula, and Tracheal esophagitis, achalasia, etc., were found during barium meal examination. Dysphagia and esophageal reflux were the most common symptoms of the esophageal diverticulum. The posterior sternal pain was usually caused by diffuse esophageal fistula.
Prevention
Upper esophageal diverticulum prevention
There is no effective preventive measure for this disease. Therefore, when there are suspicious symptoms mentioned above, it should be checked in time to achieve the purpose of early detection, early diagnosis and early treatment.
Complication
Upper esophageal diverticulum complications Complications, diffuse esophageal achalasia, esophageal hiatus hernia
Patients with upper esophageal diverticulum who underwent X-ray barium landscaping examination before surgery, endoscopy and esophageal manometry should find the following complications:
1. Esophageal motor dysfunction.
2. Diffuse esophageal spasm.
3. Achillesia of cardia (achalasia of cardia).
4. Hyper-contraction of cardiac sphincter.
5. Non-specific esophageal motor dysfunction.
6. Hiatal hernia.
Symptom
Upper esophageal diverticulum symptoms common symptoms upper abdominal pain diverticulum hemorrhoids loss of appetite dysphagia chest pain esophageal fistula
The upper esophageal diverticulum rarely causes clinical symptoms or complications, and its symptoms are directly related to the size of the diverticulum. Larger diverticulum can cause clinical symptoms, and its symptoms are accompanied by coexisting hiatal hernia or esophageal neuromuscular movement. It is related to dysfunction, not caused by the diverticulum itself.
Many patients with upper esophageal diverticulum are asymptomatic, and some patients have only mild dysphagia. Patients often use their own chewing food or eating appropriate liquid food to relieve the symptoms of dysphagia, and this method is simple and effective.
Some authors believe that the clinical symptoms caused by the esophageal diverticulum can be divided into two categories:
1 clinical symptoms caused by potential esophageal diseases (such as esophageal fistula, achalasia, esophageal dysfunction, etc.), such as eating or drinking dysphagia or poor, gastroesophageal reflux, vomiting and aspiration;
2 The clinical symptoms caused by indoor food retention and spoilage, such as bad breath, poor taste, gastroesophageal reflux, etc. Some patients have local chest pain, but the symptoms caused by these causes are easily ignored, and it is difficult to distinguish between the two. .
The most common clinical symptoms of patients with upper esophageal diverticulum are dysphagia, gastroesophageal reflux and vomiting. Gastroesophageal reflux is often spontaneous. There is no nausea before symptoms appear. It occurs when the patient is in a supine position and the patient is asleep. Among them, foods and other ingredients that are refluxed from the gastroesophageal can be inhaled into the respiratory tract. Patients are awake from sleep due to suffocation and cough. Other symptoms include pain in the back of the chest and upper abdomen, loss of appetite and weight loss, and diverticulum bleeding. Rarely, sometimes, the larger of the diverticulum can smell the "beep" in the chest.
Be1acci et al (1993) found that most of the supra-esophageal diverticulum was accidentally discovered by patients undergoing upper gastrointestinal barium meal examination for other reasons. A small number of patients often had progressive symptoms of esophageal dysfunction, including severe swallowing. Difficulties, chest pain, food retention in the esophagus, gastroesophageal reflux and aspiration are common symptoms.
Mainly rely on X-ray barium meal examination, barium meal examination can not only show the situation of the diverticulum, but also can show the changes of esophageal cavity, and determine whether other esophageal diseases are involved, suspected esophageal dyskinesia should be esophageal dynamics examination, endoscopy There is a differential diagnosis.
Examine
Examination of the upper esophageal diverticulum
In the upper digestive tract barium meal examination, if the contour of the upper esophageal diverticulum is irregular or its shape is reduced, it may indicate that the diverticulum may have cancer. The diverticulum washing solution can be used for cytological examination, which is helpful for definite diagnosis.
1. Barium meal examination: The image shows: more occurs 5~6cm above the facet, more common on the right side of the esophagus, a side wall of the esophagus is round, the mouth can be narrow or wide, the edge is smooth, the size is The contraction of the esophagus changes and the elixir is easy to store and not easily discharged. Therefore, the diverticulum is large in volume, and the density is uneven due to food residue, which is prone to infection and even necrotic perforation.
Barium meal angiography can not only show the specific location, size, diverticular sac, diverticulum neck and its direction, the shape of the diverticulum, the maximum dilatation of the esophageal lumen and the length of the local esophageal wall defect. There are no other diseases associated with the upper esophageal diverticulum, such as esophageal neuromuscular dysfunction, esophageal hiatal hernia, achalasia, esophageal stenosis or diverticular cancer, of which the most common cases of supracondylar esophageal diverticulum with hiatal hernia.
2. Endoscopy: The presence or absence of inflammation, ulceration, diverticulum cancer and esophageal obstruction can be found in the esophageal diverticulum. If the patient has upper gastrointestinal bleeding, endoscopy can confirm the source of the bleeding, and the large esophageal esophagus The diverticulum can cause the esophagus to shift, so endoscopic examination may have the possibility of perforation of the diverticulum. Special care must be taken during the examination.
The upper esophageal diverticulum can be complicated by ulcers, hemorrhage or spontaneous diverticulum perforation. In some cases, hemorrhage after diverticulum hemorrhage is more serious. Surgery can be controlled after surgical removal of the diverticulum. The diverticulum itself can cause reflux and aspiration, and aspiration can cause Aspiration pneumonia and lung abscess.
According to reports in the literature, tumors can occur in the esophageal diverticulum, such as fibroids, leiomyoma and squamous cell carcinoma. It is believed that large-sized stagnation or retention of food and secretions in the sputum, chronic infection and corruption of diverticulum contents It may promote the occurrence of cancer in the diverticulum. The esophageal barium meal angiography shows that the outline of the esophageal diverticulum is irregular or its shape is smaller than before. If there is suspected diverticulosis, esophagoscopy should be performed promptly.
3. Esophageal manometry: It is possible to identify esophageal dysfunction with esophageal diverticulum, and the results of esophageal manometry may also help determine the length of the esophageal myotomy during surgery. The functional obstruction of the esophagus was relieved, but the extent of esophageal motor abnormality could not be determined by esophageal manometry.
4.24-hour esophageal pH monitoring: If the patient has gastroesophageal reflux symptoms, a 24-hour pH check of the esophagus should be performed, and based on the results of the examination, it is determined whether the patient needs to perform an antireflux procedure at the same time.
Diagnosis
Diagnosis and differentiation of upper esophageal diverticulum
It needs to be differentiated from achalasia and esophageal hiatus.
