Esophageal compression dysphagia
Introduction
Introduction to esophageal compression dysphagia Esophageal dysphagia (dysphagiacausebyesophagealcompression) is caused by an abnormality of the aortic arch-derived blood vessels to the esophagus, tracheal compression, and clinically, the main symptoms are dysphagia and/or inspiratory dyspnea. Bayford (1794) first reported the symptoms of ectopic right subclavian artery compression of the esophagus. Sauder (1947) succeeded in the separation of the aortic rings (surrounding the trachea and esophagus). basic knowledge The proportion of illness: 0.0035% Susceptible people: no special people Mode of infection: non-infectious Complications: pneumonia
Cause
Causes of esophageal compression dysphagia
(1) Causes of the disease
Aortic arch-derived vascular abnormalities, leading to aortic growth malformation is the main cause of this disease. In the fourth week of embryonic development, the ventral aorta expands, called the aortic sac, and 6 pairs of aortic arches are separated. These 6 pairs of arteries are not At the same time, when the sixth pair is formed, the first pair and the second pair have disappeared, and their evolution is: the first, second, and fifth pairs of aortic arches are substantially degraded and disappear; the third pair of aorta roots are formed. The future common carotid artery; the fourth pair of right aortic arch forms the future innominate artery, the left side forms the future aortic arch, and the sixth pair of aortic arch forms the future left and right pulmonary artery and arterial catheter. If an abnormality occurs during the evolution, Various deformities will occur.
(two) pathogenesis
There are 4 types of abnormal aorta commonly found in clinical practice.
1. vagus right subclavian artery When the right subclavian artery directly from the arterial arch, often at the distal end of the left subclavian artery opening, becomes the fourth branch of the aorta, through the back of the esophagus to the right, you can Compress the trachea and esophagus.
2. The right aortic arch aorta does not cross the left main bronchus from the left ventricle, but extends across the right main bronchus and is connected to the descending aorta. The right aorta itself forms a vascular ring with the pulmonary artery and arterial ligament, compressing the esophagus and The trachea produces the corresponding symptoms.
3. The aortic arch ascending aorta sends out two aortic arches, one to the left and one to the right before the trachea, each crossing the corresponding bronchi, and then turning to the esophagus to form a descending aorta, forming an arterial ring that surrounds the trachea and esophagus. May be associated with other congenital heart diseases.
4. The location of the aortic arch of the cervical aortic arch rises to the level of the neck. A clinical examination reveals a pulsatile mass in the lower part of the neck, similar to an aneurysm of the innominate artery, carotid artery or subclavian artery.
Prevention
Esophageal compression dysphagia prevention
1, intravenous supplementation price nutrition
At the same time as intravenous administration of therapeutic drugs, intravenous supplementation of high-priced nutrients, such as intravenous multivitamins, fat emulsions, plasma, etc., may be used to enhance physical fitness. When infusion of nutrient solution, strict attention should be paid to aseptic operation to prevent contamination, and the infusion inspection work should be done regularly to measure body weight and judge nutritional status.
2, the dynamic observation of the condition
Careful and meticulous observation of the changes in the condition, first understand the causes of dysphagia, implement symptomatic care, tell patients the precautions, and do a good job of explaining the work, and cooperate with the doctor to make a correct judgment.
Complication
Esophageal compression dysphagia Complications pneumonia
Progression of the disease can be complicated by pulmonary infection, and most children die of suffocation due to pneumonia.
Symptom
Esophageal compression dysphagia symptoms common symptoms persistent cough dyspnea difficulty swallowing difficulty
The clinical manifestations of vascular malformation are mainly tracheal and esophageal compression symptoms. In children, respiratory tract compression is the main manifestation. In adults, esophageal compression is the main, such as dysphagia, vomiting, etc., infants and young children are typically inhaled. Last scream, persistent cough, increased respiratory rate with ischemia, hypoxia and cyanosis.
Examine
Esophageal compression dysphagia check
1. X-ray examination of dysphagia is suspected to be caused by congenital malformation of the large blood vessels in the chest, X-ray examination is feasible.
(1) Esophageal barium angiography: It is an important and simple diagnostic tool. The diagnosis method was originally reported by Neuhauser (1946). It is necessary to simultaneously photograph the chest position, lateral position and oblique position.
In patients with subclavian artery malformation and compression of the trachea, a spiral indentation can be seen in the posterior wall of the esophagus at the level of the 2nd and 3rd thoracic vertebrae in the oblique or lateral thoracic region. The characteristic is that the width is smaller than the right aortic arch, only About 1cm, and the edge is smooth, sometimes the oblique line is oblique, because the subclavian artery obliquely from the back to the upper right, is also a unique sign of this disease.
In patients with double aortic arch, the anterior and posterior and oblique chest radiographs can be seen at the level of the third and fourth thoracic vertebrae. There are two obvious incisions in the esophagus, and sometimes the incisions are not at the same level. There is a pulsating shadow around the esophagus.
The diagnosis of the right aortic arch and the left aortic catheter (ligament) is also dependent on X-ray examination. The aortic arch in the right superior mediastinum and the right esophageal contrast in the opposite direction to the normal left esophageal indentation are visible on the orthotopic chest radiograph. The lateral chest radiograph has a deep incision behind the esophagus.
(2) CT examination: chest CT can also accurately display the location, shape, range of travel and degree of esophageal compression of the deformed blood vessels. For example, when the aortic arch deformity is used, the horizontal axis of the aortic arch and the upper layer of the arch can directly display the two sides of the trachea. The right and left aortic arches, the right common carotid artery and the left subclavian artery are respectively opened in the right arch, and the corresponding right brachial artery in the left side is open to the left arch respectively, and the vascular ring pair formed by the double aortic arch can also be displayed. Compression of the trachea and esophagus (Figure 4).
(3) MIR and angiography: not only can the diagnosis of intrathoracic vascular malformation be clearly defined, but also a good vascular structure image can be provided, and the position, shape, range of travel and degree of esophageal compression of the deformed blood vessel can be accurately displayed.
2. Esophagoscopy for the ectopic position of the right subclavian artery in the esophagus. Esophagoscopy is helpful for diagnosis. At the endoscope, 2 to 3 cm below the esophageal entrance can be found in the posterior esophageal wall with signs of pulsatile arch compression. It appears as a bulge across the posterior wall of the esophagus, and its pulsation is consistent with the pulse. At this time, if the bulge is pressed at the end of the esophagus, the pulsation of the right iliac artery of the patient may be weakened or even disappeared depending on the degree of compression. The pulsation of other arteries is not affected. When the compression is released, the right iliac artery pulsation returns to normal. Endoscopy combined with X-ray examination features can confirm the diagnosis. This feature can also be used as a differential diagnosis with benign esophageal tumors.
In patients with a double aortic arch and a right aortic arch and a left aortic catheter (ligament), esophagoscopy revealed a pulsatile bulge due to vascular malformation on the posterior esophageal wall and a pulse consistent with the pulse.
3. Ultrasound examination
(1) Two-dimensional echocardiography: It is of great value in the diagnosis of large blood vessel malformation in neonates and infants. Two-dimensional echocardiography is used to detect the sternal and high sternal areas, and the right aortic arch and left name can be found. Arterial malformation, when the left unnamed artery is found to have no normal branch, the left subclavian artery alone from the aortic arch descending, suggesting to be vagus left subclavian artery, the left subclavian artery is separated by the proximal end of the artery catheter (ligament), so Difficult to identify.
(2) Color Doppler: The branching, size and direction of the deformed thoracic blood vessels have a great reference significance for the relationship with adjacent organs. The extent of esophageal and tracheal involvement can be found. Great diagnostic significance.
Diagnosis
Diagnosis and diagnosis of esophageal compression dysphagia
Determining the diagnosis mainly depends on X-ray examination to understand the location, type and extent of vascular malformation and esophageal compression.
1. Lost right subclavian artery accounts for about 23% of vascular malformations.
(1) Malformation characteristics: As the proximal segment of the right aorta disappears, the aorta between the left common carotid artery and the left subclavian artery is shortened, so that the right subclavian artery opening is located distal to the opening of the left subclavian artery. Become the 4th branch of the aortic arch, and the other 3 branches from right to left are the right neck, the left neck and the left subclavian artery. The migrating right subclavian artery is obliquely to the upper right and over the middle line. The top of the pleura reached the right upper arm, and about 15% of the deformed blood vessels passed between the trachea and the esophagus, and 5% passed through the trachea.
(2) Clinical manifestations: Children with symptoms of respiratory depression, adults with difficulty swallowing, because the initial part of the blood vessels expand with age, so most patients found later, this deformity combined with congenital heart disease accounted for 10%.
(3) Auxiliary inspection:
1 Esophageal X-ray angiography showed a smooth spiral filling defect in the aortic plane from the lower left to the upper right, and the right anterior oblique position showed that the esophagus showed a spherical indentation above the aortic arch.
2 Esophagoscopy showed that there was arterial pulsation in the stenosis, the mucosa was normal, the pulsation was compressed with a hard tube, and the right pulse was weakened, which could be differentiated from tracheal tumor.
2. The double aortic arch accounts for 48% of vascular malformations.
(1) Malformation characteristics: the junction between the right aorta and the left aorta is paused during embryonic development, forming a double aortic arch. Under normal circumstances, the left anterior arch is smaller and the right posterior arch is larger, and the two surround the trachea. esophagus.
(2) Clinical manifestations: Children with obvious dyspnea and difficulty swallowing, manifested as symptoms of tracheal compression during infancy, such as shortness of breath, wheezing, and even snoring, when the child takes the neck overextension, There are varying degrees of relief, and clinically, there are quite a few patients without symptoms.
(3) Auxiliary examination: Esophageal barium meal or lipiodol imaging showed two indentations or annular stenosis before and after the level of aortic arch.
3. The right aortic arch accounts for approximately 30% of vascular malformations.
(1) Malformation characteristics: the left aortic arch of the embryonic stage forms the proximal segment of the left subclavian artery, the right fourth arch forms the aortic arch, the right side of the esophagus and trachea rises, the trachea and esophagus are located in the left front, and the arterial ligament bypasses the trachea. The left posterior part of the esophagus connects the aortic arch and the pulmonary artery to form a ring at the end of the esophagus.
(2) Clinical manifestations: Patients have obvious dyspnea and dysphagia.
(3) Auxiliary examination: X-ray examination showed the right side of the aortic arch, and the signs of compression were seen in the esophagus; esophagoscopy showed a pulsatile external pressure stenosis at the level of the aortic arch.
4. Cervical aortic arch
(1) Malformation characteristics: the position of the aortic arch rises to the level of the neck.
(2) Clinical manifestations: Half of the patients may have tracheal and esophageal compression symptoms, and a physical examination may reveal a pulsatile mass in the lower part of the neck, similar to an aneurysm of the innominate artery, carotid artery or subclavian artery.
