penetrating injury of the esophagus
Introduction
Introduction to esophageal penetrating injury Penetrating injury of esophagus, including lesions of the esophagus itself, large or relatively sudden forces acting on the esophagus, lesions around the esophagus, and chemical damage. basic knowledge The proportion of illness: 0.005% Susceptible people: no special people Mode of infection: non-infectious Complications: mediastinal emphysema, pneumothorax, meningitis
Cause
Causes of esophageal penetrating injury
(1) Causes of the disease
1. Iatrogenic trauma.
2. Esophageal foreign body.
3. Esophageal lesions.
(two) pathogenesis
1. Iatrogenic trauma:
Including esophageal dilatation treatment, anesthesia intubation, esophageal varices sclerotherapy, endoscopy (including gastroscope and duodenoscopy), violent force, endoscopic foreign body and accidental injury during surgery, in addition to fiberoptic bronchoscopy and insertion Gastric tube may also cause esophageal perforation accidents. Esophageal dilatation treatment is prone to esophageal perforation when balloon dilatation is used to treat achalasia, and endoscopic guided dilatation of the instrument to cause esophageal perforation is not uncommon. Generally speaking, In order to achieve the purpose of treatment, the achalasia must be able to tear part of the muscle layer by the pressure inside the balloon. From the operator's intuition, there is a small amount of bleeding under the microscope, but the degree is often difficult to grasp, if concurrent Patients with esophageal hiatus hernia or supraorbital diverticulum are more likely to undergo perforation during dilatation; esophageal varices sclerotherapy is often life-threatening, and a large amount of sclerosing agent such as anhydrous alcohol and ethoxylated alcohol in the varicose veins may cause perforation of the esophagus. Sexually increased, but intravascular injection of tissue adhesives generally does not appear perforation; endoscopic foreign bodies are particularly large and sharp The foreign body is more likely to cause perforation; the perforation caused by the three-chamber two-capsule tube compression hemostasis is more common, which is related to the excessive inflation of the esophageal sac and the excessive compression time.
2. Food foreign bodies:
Common fish bones, chicken bones and toothpicks, and the accidental swallowing of metal foreign bodies occur more frequently in the physiological stenosis of the esophagus.
3. Esophageal lesions:
Esophageal chemistry, physical burns, esophageal cancer, acute inflammation of the esophagus, chronic perforation of esophageal cancer may be complicated by esophageal-bronchial spasm.
Prevention
Esophageal penetrating injury prevention
1. Iatrogenic trauma:
When performing anesthesia intubation, esophageal varicose sclerotherapy, endoscopy, etc., do not use force to prevent accidental injury to the esophagus.
2. Esophageal foreign body:
Prevent fish bones, chicken bones, toothpicks and other foreign objects from swallowing into the esophagus.
3. Esophageal lesions:
Prevent esophageal chemistry, physical burns, and pay attention to the possible appearance of esophageal cancer with perforation.
Complication
Esophageal penetrating injury complications Complications, mediastinal emphysema, pneumothorax meningitis
After the esophagus rupture, it causes mediastinal inflammation, mediastinal emphysema, pneumothorax, hydrothorax and empyema (the latter three are often on the left side, but also affects both sides), dyspnea is accompanied by cyanosis, due to the volume of gas and fluid in the mediastinal soft tissue With the heartbeat and respiratory motion pulling the mediastinal soft tissue to produce the friction sound (Hamman murmur), in the anterior region can hear a snoring synchronized with the heartbeat, due to mediastinal emphysema, gas from the mediastinum into the subcutaneous tissue of the neck, press There are typical sputum pronunciations, some patients may have no typical symptoms and signs, and very few cases first manifested as meningitis caused by secondary central infection.
Symptom
Esophageal penetrating injury symptoms Common symptoms Abdominal muscle tonic sternal pain Swallowing difficulty Chest pain Varicose abdominal pain Black stool Esophageal dilatation of the sacral effusion above the glottis
Esophageal perforation mainly manifests as retrosternal pain, abdominal pain, fever, dysphagia, subcutaneous emphysema, melena and even hematemesis. Some patients may have no obvious symptoms. Patients with lower perforation may have abdominal muscle rigidity and chest with pleural effusion. The percussion is a real sound.
Examine
Esophageal penetrating injury examination
When the disease is combined with massive hemorrhage, the total number of red blood cells and hemoglobin in the blood are reduced.
X-ray examination is the most important examination method, not only can determine the presence or absence of perforation, but also can locate the perforation. X-ray examination reveals mediastinal emphysema, left pneumothorax, pleural effusion, liquid pneumothorax can be diagnosed, and chest radiograph If the perforation is not confirmed, a small amount of water-soluble contrast agent can be swallowed. If a contrast agent overflow is found, it can be diagnosed and positioned immediately.
Diagnosis
Diagnosis and diagnosis of esophageal penetrating injury
diagnosis
The prognosis of esophageal perforation is related to the early treatment of the corresponding treatment, so early diagnosis is very important.
1. Perforation of esophageal foreign body: foreign body is usually longer, early symptoms are not typical, some cases may be complicated by esophageal-thoracic aortic fistula, chest X-ray examination may be non-specific, endoscopic examination must be careful and gentle, esophagography for diagnosis helpful.
2. Esophageal dilation treatment of perforation: endoscopic esophageal balloon dilatation should be carefully examined after the lower esophageal and gastric mucosal tear state, the general patient will have post-sternal pain and other symptoms during dilation, if the patient is suffering from chest pain after dilation Progressive aggravation, to consider whether the esophagus has been perforated, such patients are closely observed after surgery is very important.
3. Esophageal varices sclerotherapy: the incidence is low, once the patient has chest pain, fever, should pay attention to alert to esophageal perforation.
4. Esophageal angiography: esophageal angiography is highly specific, generally water-soluble contrast agent is ideal, because it is less irritating to the mediastinum, contrast agent leakage is the direct basis for diagnosis, but should be alert to a small number of esophageal perforators Perforation caused by sharp foreign bodies often leads to false negatives such as contrast-free spillage.
5. Chest CT examination: chest CT examination can confirm whether there is mediastinal gas accumulation, and can reveal the location of perforation and whether there is fluid or empyema.
6. Endoscopy: Although the area of esophageal perforation, especially foreign body damage, can be clearly identified, it is important to remember that the operation should not be rude, and do not over-inflate, otherwise the perforation may be aggravated.
7. Other examinations: Oral blue can be taken when pleural effusion occurs. At this time, if the chest drainage is found, the blue staining can be immediately confirmed.
Differential diagnosis
The diseases that need to be differentiated are pleurisy, spontaneous pneumothorax, aortic dissection aneurysm, acute myocardial infarction, acute pancreatitis, peptic ulcer perforation, cholelithiasis, intestinal obstruction, pulmonary embolism, etc., other causes of mediastinal emphysema Chest pain is not affected by swallowing movements.
