Pharyngoesophageal diverticulum
Introduction
Introduction to the pharyngeal esophagus The mucosal layer or the whole layer of the esophageal wall protrudes outward from the esophageal lumen, forming a saclike protrusion communicating with the esophageal lumen, which is called an esophageal diverticulum. The esophageal diverticulum is mostly an acquired disease, which is common in adults. There are also congenital esophageal diverticulum formation. Occurs at the junction of the pharyngeal tube, also known as the Zenker chamber. basic knowledge The proportion of illness: 0.005%-0.007% Susceptible people: common in adults Mode of infection: non-infectious Complications: malnutrition lung abscess atelectasis asthma
Cause
Causes of pharyngeal esophagus
(1) Causes of the disease
The etiology of the pharyngeal esophageal diverticulum is not fully understood. Because the disease is more common in patients over 50 years old and rare in people under 30 years old, it is generally considered to be an acquired disease.
Negus (1950) believes that the cause of the pharyngeal esophageal diverticulum may be due to the anatomical weak points (zones) of the pharyngeal muscles and the obstruction of the esophageal lumen at the distal end of the pharyngeal muscle. The main reason is that the pharyngeal esophageal diverticulum always occurs in the pharynx. Above the muscle, although some authors speculate that the occurrence of this disease may be related to obstruction at the junction of the pharyngeal esophagus, Mayo Clinic et al (1969) confirmed this by manometric studies of the esophageal lumen of patients with pharyngeal esophageal diverticulum. There is no achalasia or hypertonia in the pharyngeal muscles of patients. Some authors have found that there is a contraction between the pharyngeal esophageal diverticulum and the pharynx and the pharyngeal sphincter flaccidity and contraction during swallowing. Temporary abnormal relationship, in patients with pharyngeal esophageal diverticulum, the contraction of the upper esophageal sphincter occurs before the pharyngeal contraction is completed. Therefore, the early contraction of the pharyngeal sphincter is the cause of the disease.
In some small, early, and large cases of pharyngeal esophageal diverticulum, early contraction of the pharyngeal sphincter can also be seen, indicating that the motor dysfunction of the pharyngeal muscle is the underlying cause of the disease. One.
In 1988, Lerut et al. studied the muscle composition of the upper esophageal sphincter region. It was found that myogenic degeneration and neurogenic diseases could not limit the function of the pharyngeal muscle, but could affect the striated muscle. Therefore, some authors believe that the circumflex muscle movement Dysfunction is one aspect of a more complex functional problem than the disease itself, and the pharyngeal esophageal diverticulum is merely a manifestation of the motor dysfunction of the pharyngeal muscle.
In 1992, Cook et al. used video radiography and manometry to conduct a controlled study of Zenker's diverticulum. The results showed that the open function of the upper esophageal sphincter in the Zenker's diverticulum was significantly weakened and the pressure in the diverticulum. Significantly increased, therefore, Cook et al believe that one of the major abnormal changes in the Zenier diverticulum is due to the open dysfunction of the upper esophageal sphincter, rather than the contraction of the pharyngeal muscle and the dysfunction of the opening or relaxing function of the upper esophageal sphincter. If the patient's pharyngeal muscle function is impaired during swallowing, the transmural pressure in the general esophageal cavity during swallowing can cause the mucosa of the pharyngeal esophagus to pass through the anatomical weak point of the posterior pharyngeal wall above the pharyngeal muscle. Backwardly, the pharyngeal esophageal diverticulum is formed. As the pressure in the pharyngeal esophageal lumen is repeated and the food in the diverticulum cavity or in the sac is continuously retained, the pharyngeal esophageal diverticulum gradually increases and sag.
The diverticulum of the pharyngeal esophageal diverticulum is suspended above the pharyngeal muscle, and the diverticulum sac is between the esophagus and the cervical vertebra. The location of the severe or advanced pharyngeal esophageal diverticulum can be perpendicular to the longitudinal axis of the pharynx, thereby making the diverticulum sac selective. Filling and compressing the esophagus, and the diverticulum is anteriorly angled with its adjacent esophagus. However, because the diverticulum is above the pharyngeal muscle, it does not prevent the spontaneous emptying of the diverticulum, and the patient often has a laryngeal tracheal aspiration (1aryngotracheal aspiration) And the contents of the diverticulum flow back into the cavity.
In the posterior part of the junction of the pharynx and the esophagus, there is a hypopharyngeal muscle, and there is a circumflex pharyngeal muscle underneath. There is a small triangular area between the two muscles, called the Killian triangle, which lacks muscle fibers in the triangle. It is a weak point or weak area of human anatomy, and it is also a good disease position of the pharyngeal esophageal diverticulum. Because this weak area is more obvious on the left side, the pharyngeal esophageal diverticulum mostly occurs on the left side.
It is generally believed that the pharyngeal muscle plays an important role in the pathogenesis of the pharyngeal esophageal diverticulum. Its autonomic innervation is the vagus nerve, which is distributed in the posterior wall of the annular cartilage. The pharyngeal muscle is contracted under normal conditions, while swallowing, vomiting and suffocating. Relaxation, when the food enters the pharynx, the inferior pharyngeal muscle contractes, the pharyngeal muscle relaxes, and the food descends to the esophagus without obstruction. After the food passes through the pharyngeal muscle, the muscle returns to the contracted state, and the pharyngeal muscle Coordinating action can ensure that the swallowed food smoothly enters the stomach through the esophagus and prevents aspiration during the feeding process. Therefore, the physiological function of the pharyngeal muscle is like the upper esophageal sphincter, which causes dysfunction of the two muscles for some reason. That is, when the swallowing contraction muscle contracted while swallowing and the pharyngeal muscles could not relax, the pressure in the pharyngeal cavity above the pharyngeal muscle increased, and the tissue structure of the weaker Killian triangle region bulged outward. This is the pharyngeal esophageal diverticulum. The initial pathophysiological changes were formed, and the tissue structure of the Killian triangle gradually enlarged outward, forming a typical pharyngeal esophageal diverticulum.
There are many reasons for the coordination of pharyngeal dysfunction. For example, with the increase of age, the pharyngeal muscle-prevertebral fascia is fixed and loose, leading to the muscle dysfunction or disorder; gastroesophageal reflux may cause an increase in pharyngeal pressure, etc. Most authors believe that the contraction of the inferior pharyngeal muscle and the relaxation of the circulatory pharyngeal muscle, achalasia or other dyskinesia, coupled with the anatomical features of the Killian triangle, is the main cause of the pharyngeal esophageal diverticulum.
(two) pathogenesis
The pharyngeal esophageal diverticulum is often formed and developed according to the following process.
1. Normal swallowing exercise exerts pressure on the esophageal wall, and in the anatomical weak area of the esophageal muscle layer or the lack of the muscular layer, this pressure can cause the esophageal mucosa to be exfoliated (outstanding) through the anatomical weak area, a few years later. A blind pouch, the diverticulum, is gradually formed.
2. Due to the repeated action of high pressure in the esophageal lumen during swallowing movement, and the retention of food debris and secretions in the sputum, the diverticulum gradually increases.
3. As the diverticulum continues to increase, it descends between the esophagus of the posterior mediastinum and the anterior fascia, and the anterior fascia can compress the esophagus and make it angled. At this time, the longitudinal axis of the esophageal lumen ( The main shaft is displaced forward in the direction in which the pharynx and the diverticulum are angled to the right.
4. Since the food often enters the pharyngeal esophagus chamber when swallowing food, the passage of the food in the sputum into the esophageal lumen is only done by the dumping of the sputum into the esophageal lumen. Therefore, once the pharyngeal esophageal diverticulum is present, In the formation, a certain volume will increase rapidly, and the clinical symptoms will be progressively aggravated. The time during which the indoor food passes into the esophageal lumen and the size of the diverticulum often change with the relationship between the diverticulum opening and the esophageal longitudinal axis. The diverticulum opening is at right angles to the esophageal lumen; in the later stage of the disease, the diverticulum opening and the esophageal lumen gradually become acute angles, and finally the diverticulum opening is in a horizontal or horizontal position; the diverticulum sac continues to sag, the diverticulum opening becomes part of the esophageal opening, and the pharyngeal esophagus The development and evolution of diverticulum openings can be divided into Phase I, Phase II and Phase III.
Prevention
Pharyngeal esophagus diverticulosis prevention
There is no effective preventive measure for this disease. Early detection and early diagnosis are the key to the prevention and treatment of this disease.
Complication
Venous esophageal diverticulum complications Complications, malnutrition, lung abscess, atelectasis
If the pharyngeal esophageal diverticulum is not taken seriously after diagnosis, missed diagnosis or misdiagnosis without treatment, the patient may have the following potential complications:
1. Chronic malnutrition Long-term poor swallowing and esophageal reflux can lead to chronic malnutrition.
2. Respiratory aspiration in the elderly or diabetic patients, the earliest clinical symptoms of the pharyngeal esophageal diverticulum may be pulmonary infectious complications, such as lung abscess, atelectasis, etc., this is caused by reflux food aspiration, most often Occurred in the right lower lobe, a small number of cases can cause respiratory insufficiency, individual cases have asthma.
3. The recurrent laryngeal nerve is compressed by a large pharyngeal esophageal diverticulum to compress the recurrent laryngeal nerve. The patient has symptoms such as hoarseness.
4. Esophageal obstruction Sometimes, patients with pharyngeal esophageal diverticulum suddenly have high cervical esophageal obstruction due to swallowing foreign bodies or overeating. There may be no symptoms or discomfort before.
5. Perforation of the diverticulum Occasionally, the patient is perforated in the diverticulum due to the ingestion of sharp foreign objects (such as chicken bones). In this case, the esophageal diverticulum is easily missed, and any esophageal intubation or endoscopy It may also cause perforation of the diverticulum, so the endoscopic examination of the patient with pharyngeal esophageal diverticulum should be highly alert to the possibility of perforation of the iatrogenic diverticulum.
6. Diverticulitis The food in the diverticulum sac is blocked by the neck of the diverticulum and can not be ruled out, which can lead to dilated mucosal erosion and diverticulitis.
7. Carcinogenesis In 1969, Wychulis et al reported that 3 cases of pharyngeal esophageal diverticulum were cancerous.
Symptom
Pharyngeal esophageal diverticulum symptoms common symptoms cough gas over water sound abscess esophageal obstruction
1. Symptoms and signs Patients with pharyngeal esophageal diverticulum can have no clinical symptoms, but most patients have symptoms in the early stage of the disease. Once the diverticulum is formed, its volume will gradually increase, and the patient's symptoms will gradually increase, the frequency of symptoms may be The number of times is increasing and complications may occur.
Typical clinical symptoms of patients with pharyngeal esophageal diverticulum include difficulty in swallowing of the high neck esophagus, respiratory odor, pharynx when swallowing food or drinking water, whether coughing or not coughing, patients often have spontaneous esophagus The reflux of the contents, the typical reflux is fresh, undigested food, no bitter or sour taste, or does not contain gastroduodenal secretions, and individual patients develop esophageal reflux immediately after eating. The regurgitation is related to the severe cough and suffocation caused by the aspiration of the contents of the diverticulum into the airway. Due to esophageal reflux and cough, the patient's feeding process is slow and laborious.
As the volume of the pharyngeal esophagus continues to increase, the patient's pharynx often has a feeling of bloating, and the feeling of the patient's neck is suppressed by hand. This feeling can be alleviated or alleviated. Occasionally, the patient's odor caused by the decomposition of the contents of the diverticulum In the case of a visit, very few patients complained that there was a soft mass in their neck.
2. Clinical staging Some authors divided the clinical symptoms of the pharyngeal esophageal diverticulum into three phases.
Stage I: The diverticulum is small, the opening is at right angles to the longitudinal axis of the esophagus. The patient has no cervical esophageal obstruction, no esophageal reflux or diverticulum contents. The main symptom of the patient is a foreign body sensation in the throat and attempts to cough or cough. Excluding the "foreign matter", the predisposing factor is often to eat a piece of dry food (such as toast, etc.), and when it is spit out, the foreign body sensation in the throat disappears.
Stage II: After the pharyngeal esophageal diverticulum is enlarged to a certain extent, the opening of the diverticulum is oblique to the diverticulum. The main symptom is that the patient's oral cavity suddenly discharges the original diet and is mixed with mucus and saliva. This symptom can occur. In sleep, it can lead to aspiration, the patient is awake from sleep due to paroxysmal cough, and aspiration can cause lung abscess, which should be taken seriously. Some patients have gurgling noise or "gurgling noise" when swallowing. The sound of Titicaca is the sound produced by the mixing of gas and liquid in the chamber of the chamber.
Stage III: After the diverticulum sac is enlarged to a certain size, the diverticulum opening is in a horizontal or horizontal position. The swallowed diet can directly enter the diverticulum. The patient may develop other symptoms, such as different degrees of high neck esophageal obstruction, accompanied by partial or Esophageal reflux in all foods, such patients often have weight loss and emecation.
Examine
Inspection of the pharyngeal esophagus
Should be done routine hematuria, liver and kidney function and other general examinations.
1. Esophageal barium meal angiography The clinical diagnosis of pharyngeal esophageal diverticulum relies on esophageal barium meal angiography. After phagocytosis, the patient can see through the fluoroscopy and radiography (photographing the esophagus and lateral radiographs), which can clarify the position and size of the diverticulum, the thickness of the diverticulum neck and Emptying and the relationship between foraging and the esophageal axis.
In the esophageal barium meal, once the ingested tincture is filled or enters the diverticulum, the pharyngeal esophageal diverticulum containing the fistula is located at the lower edge of the affected esophagus. The esophagus above the diverticulum sometimes becomes thinner or the lumen shrinks, which is easily mistaken for filling with tincture The diverticulum was caused by compression, but no matter from which angle the stenosis was observed, the stenosis of the affected esophageal segment was uniform and narrow, which was quite different from the stenosis caused by local esophageal compression. A clear incision was seen at the posterior edge of the esophagus at the level of the pharyngeal muscle, which was caused by compression of the posterior esophageal wall of the pharyngeal esophagus.
Some authors advocate that X-ray barium meal angiography should be performed as much as possible in patients with pharyngeal esophageal diverticulum. Gastroesophageal reflux or reflux esophagitis caused by simultaneous esophageal hiatal hernia and circumflex pharyngeal dysfunction should be sought as much as possible.
On the esophageal barium meal, the pharyngeal esophageal diverticulum is often round, oval or pear-shaped, located at the edge of the affected (onset) esophagus, generally with a thin diverticular neck, on the standing X-ray barium meal, swallowed The sputum into the sac of the sac, the air and the liquid are three layers, and may show the mucosal image on the surface of the enamel. The mucosa in the neck of the diverticulum is sometimes the clearest. The mucosal folds of the diverticulum can accumulate in the neck of the diverticulum. The diverticulum is distributed in a fan shape, and the entire contour of the diverticulum is clear on the X-ray film and the edges are smooth.
Lahev warren stressed that if the sacral esophageal diverticulum is found to have irregular or uneven cavities in the sacral angiography, it is necessary to pay attention to the possibility of malignant lesions or cancer growth in the sputum. According to the literature, pharyngeal esophageal cancer is in the diverticulum. After diverticulectomy, the patient's prognosis is better.
2. Esophagoscopy The clinical diagnosis of the pharyngeal esophageal diverticulum usually does not require esophagoscopy. However, if the diverticulum is combined with a tumor, the patient has other organic lesions causing symptoms, or if there is a foreign body in the sputum, esophagoscopy should be performed. ) check, but be extra cautious during the examination to avoid inserting the lens of the endoscope into the diverticulum sac and causing instrumental perforation of the diverticulum. Individual esophageal sinus esophagoscopy can be found by esophagoscopy. Esophageal stricture, esophageal fistula or esophageal cancer.
Diagnosis
Diagnosis and diagnosis of pharyngeal esophagus
Diagnostic criteria
The clinical diagnosis of the pharyngeal esophageal diverticulum mainly depends on the medical history, physical examination and esophageal X-ray barium meal examination, and the latter plays a key role in the diagnosis.
1. Patients with pharyngeal esophageal diverticulum may have the following signs when examining the body:
(1) The paralyzed patient drinks water and auscultates in the cervical diverticulum when swallowing, and can hear the sound of gas over water or "tick".
(2) McNealy-McCallister test: This simple clinical trial is used to determine the location of the pharyngeal esophageal diverticulum at the neck (side).
method:
1 The patient takes a seat and faces the examiner;
2 After the patient has swallowed the air several times, the examiner puts his left thumb on the front of the patient's right neck sternocleidomastoid cartilage horizontally and gently squeezes it with the thumb;
3 The examiner repeatedly squeezes the corresponding part of the patient's right neck with his right thumb;
4 When the examiner's thumb is squeezed on the neck of the side of the pharyngeal esophagus, the trachea in the chamber is discharged through the liquid due to the pressing action of the thumb, so the examiner can hear the patient's affected neck and the air Water sound.
2. Auxiliary inspection
Esophageal barium meal can be seen on the edge of the esophagus with a round, oval or pear-shaped pharyngeal esophageal diverticulum, swallowed into the diverticulum sac in the sputum, air and liquid in 3 layers; esophagoscopy, visible sputum indoors have foreign bodies, individual patients have Esophagitis, esophageal stricture, esophageal fistula or esophageal cancer.
Differential diagnosis
Should be differentiated from esophagitis, esophageal stricture, esophageal fistula or esophageal cancer.
