Esophageal webs and esophageal rings
Introduction
Introduction to esophageal fistula and esophageal ring Esophageal web and esophagealring are easily confused with esophageal muscle contraction and stenosis. Strictly speaking, esophageal fistula is a thin (2 to 3 mm) fragile sputum consisting of only the mucosa and submucosa in the esophageal lumen. The septum can be seen in any part of the esophagus. The esophageal ring is often referred to as a thick and tough narrow ring composed of the esophageal mucosa and muscular layers. The X-ray findings are indistinguishable, so the esophageal fistula and ring should be identified based on symptoms, signs, X-ray signs, esophageal manometry, and endoscopic biopsy. basic knowledge Sickness ratio: 0.001%-0.005% Susceptible people: no special people Mode of infection: non-infectious Complications: esophageal rupture
Cause
Esophageal fistula and esophageal ring cause
(1) Causes of the disease
Esophageal fistula may be formed by vacuoles during esophageal development during embryonic period, and vacuol fusion is incomplete, leaving part or complete mucosal annular aponeurosis; it is also thought to replace the squamous cells of villous columnar cells during esophageal development. The epithelial overgrowth is caused by the esophageal stenosis caused by the excessive proliferation of the mesodermal components during the formation of the esophageal muscle layer during the embryonic period.
(two) pathogenesis
The esophageal fistula and esophageal ring are morphologically belong to the mucosal ring and the muscular ring respectively. The mucosal ring is composed of connective tissue, mucosa and blood vessels, and the surface is covered with a layer of squamous epithelium; the muscle ring is composed of thickened annular muscle bundle. There can be a number of inflammatory cells, which separate the esophagus from the stomach and prevent acid reflux.
Further, the ring composed of the inflammatory aponeurosis may be fibrotic at a later stage, and a wheel-like stenosis may occur, forming a structure called a third type of annulus, which is different from the esophageal fistula and the ring described above.
According to the position of the ankle and the ring in the esophagus, the upper, middle and lower esophageal fistula and the lower esophageal ring are divided.
Upper esophageal fistula (36%):
The esophageal mucosa formed by the esophageal mucosa has a unique anatomical and gender characteristics, 90% of which are female, and the age of onset is 30 to 50 years old. The infant has a case report, which may be a congenital cause, or it may be Related to iron deficiency anemia, the main symptoms are iron deficiency anemia and dysphagia. The disease is mainly distributed in the northern hemisphere. In patients with iron deficiency anemia in this area, about 15% have upper esophageal fistula. Iron dysphagia is also known as Plummer-Vinson syndrome or Pattersen-Kelley syndrome.
Most scholars believe that iron deficiency is the basic factor of this disease, causing dysphagia in esophageal epithelial changes. Clinical use of iron therapy can alleviate dysphagia, but esophageal fistula, iron deficiency, and dysphagia may not be related. .
Middle and lower esophageal fistula (25%):
Middle esophageal fistula is a mucosal diaphragm composed of normal or inflammatory epithelium. It is rare, both men and women can develop disease. Adults are more than infants, and most patients are asymptomatic. The lower esophageal fistula is also a mucosal membrane with a thickness of about 1 to 2 mm. It is usually located 2 cm above the junction of the esophageal columnar epithelium. The surface is covered with a layer of keratinized squamous epithelium with a few inflammatory cells under the mucosa.
Lower esophageal ring (15%):
The lower esophageal ring is located in the squamous epithelial ring at the junction of the esophagus and gastric mucosa. It is also a contraction ring composed of mucosa or muscular diaphragm (Schatzki ring). When the inner diameter of the esophageal lumen is less than 20mm, dysphagia may occur. When the diameter is equal to or less than 13 mm, it is sure to cause difficulty in swallowing, which is called a symptomatic lower esophageal ring.
Prevention
Esophageal fistula and esophageal ring prevention
There are no effective preventive measures for this disease. Early detection, early diagnosis and early treatment are the key to the prevention and treatment of this disease. Once the disease occurs, it should be actively treated to prevent the occurrence of complications.
Complication
Esophageal fistula and esophageal ring complications Complications
Esophageal obstruction is one of its complications, such as repeated attacks, causing esophageal dilation, which can lead to spontaneous rupture of the esophagus.
Symptom
Esophageal fistula and esophageal ring symptoms Common symptoms Mucinous edema Esophageal symmetry swelling Malignant anemia Kneeling esophageal dilatation Burning heart nipple disappeared esophageal obstruction
Patients with upper esophageal sputum are generally asymptomatic, mostly in the case of eating hard food. The main manifestations are intermittent dysphagia, food retention on the chest, Plummer-Vinson syndrome often has weight loss, pale, sometimes red, tongue The quality is red and smooth, the tongue nipple disappears, most of the missing teeth or completely without teeth, the mouth is splitting, the key finger, the spleen, and even the spleen, and then the dysphagia, can be clearly diagnosed.
Middle esophageal fistula is mostly asymptomatic. If intermittent vomiting or sudden esophageal obstruction occurs in infants over 5 to 11 months, congenital middle esophageal fistula should be considered. The cause of esophageal fistula in adults is unknown, which is characterized by hard swallowing. Intermittent ingestion is difficult when the food is present, and there is a feeling that the food is stagnated behind the sternum.
The clinical features of the lower esophageal fistula are similar to those of the lower esophageal ring. Intermittent dysphagia is the main symptom of the lower esophageal ring. When eating in a hurry, the patient has the feeling that the bolus occludes the esophagus and cannot swallow. At this time, the patient tries to spit out the food or Drinking water and rushing out of the group to relieve symptoms, so if it works, the patient will learn from it, in order to avoid the difficulty of swallowing due to rushing to eat, and in the subsequent feeding process, slowly chew, weeks Similar symptoms will not occur in a few months, because the lower esophageal ring can prevent acid reflux, and the patient has no heartburn symptoms. However, after repeated expansion treatment, although the difficulty of swallowing can disappear, the anti-reflux barrier can be destroyed, which can occur. Reflux esophagitis, Eastridge (1984) found that 88 cases of esophageal ring patients have sliding esophageal hiatal hernia, there may also be reflux symptoms, esophageal obstruction is one of its complications, such as recurrent episodes, causing esophageal dilation Can cause spontaneous esophageal rupture.
Examine
Examination of esophageal fistula and esophageal ring
If you suspect that the upper esophagus is required to rely on X-ray examination, the anterior wall of the upper esophagus can be found to be eccentric, less than 2mm wide, more than one is rare, the endoscopy is a smooth, colored eccentric The open diaphragmatic hole is located below the level of the pharyngeal muscle. The thin film is not found by the examiner. It is rare to block the rough sputum that passes through the food. Because about 70% of patients with oral cancer have a long time. A history of Plummer-Vinson syndrome, if necessary, a cytological brush or biopsy of endoscopic esophageal fistula to exclude stenosis or cancer. The middle esophagus is not like the former, there is no obvious gender difference, and it is asymptomatic. Even if it is, its only symptom is difficulty in swallowing. Sometimes a thin (1~2mm thick) tincture filling defect is found only on X-ray examination. The upper and lower esophagus of the sputum expands to the same extent. The X-ray features of the lower esophageal fistula are different from the middle esophageal fistula and the lower esophageal ring. The proximal end (head end) of the tendon is symmetrical with the esophagus, and the distal end (the vestibule of the esophagus) has a double concave surface.
When the patient takes a lateral position for Valsalva action, the esophageal lumen of the lower esophageal ring can be dilated, the esophageal ring can be easily displayed, thereby positioning, and measuring the diameter of the ring, which is opposite to the lower esophageal fistula, in the ring The proximal end is double concave, the distal end is adjacent to the stomach. When the esophagus is examined, the lower part of the esophagus is fully inflated first, and the esophagus is clearly visible. The biopsy under direct vision excludes esophagitis and esophageal cancer.
Diagnosis
Diagnosis of esophageal fistula and esophageal ring
Diagnostic points
Combined with endoscopy, it can be differentiated from esophageal cancer, esophageal stenosis, and esophageal muscle contraction.
