foreign body in esophagus
Introduction
Introduction to foreign bodies in the esophagus Foreign body in the esophagus (foreignbodyinoesophagus) is one of the common emergencies, which can occur at any age, with the majority of the elderly, followed by young children. Because large foreign bodies can temporarily stay in the lower part of the pharynx or at the entrance to the esophagus, it can block the airway and cause serious complications, even life-threatening, so it must be treated in time. basic knowledge The proportion of illness: 0.005% Susceptible people: no special people Mode of infection: non-infectious Complications: abscess chronic mediastinal inflammation
Cause
Cause of foreign body in the esophagus
Dietary habits (12%):
1 Coastal areas are accustomed to mixing fish, shrimp, vegetables and mixed food, easy to cause small fishbone, fish bones swallowed, 2 northern scorpion contains a nuclear jujube or boned meat mass, easy to cause a swallow, 3 North Customs in the festival is built of metal coins in the dumplings, which is easy to cause swallowing.
Disease factors (20%):
1 esophageal esophageal neoplasms, esophageal scar stenosis, etc., resulting in food or small food retention, 2 mediastinal lesions mediastinal tumor or abscess formation lesions, oppression of the esophagus, resulting in esophageal stricture, easy to retain food or small foreign bodies, 3 neuropathy The disappearance of pharyngeal reflex or the loss of swallowing reflex is easy to cause swallowing.
Children eating accidents (25%):
Common causes of children's esophageal foreign body: A. Children's nature is naughty and likes to put a coin badge or other small items into the mouth and occasionally inadvertently swallowed into the esophagus; B. Insufficient swallowing function with bone spurs or nuclear Food inadvertently swallowed; C. eating crying or playful, easy to swallow the food in the mouth or swallow foreign body; D. molar incomplete food without swallowing, swallowing to cause esophageal foreign body.
Mental factors (10%):
When you fall asleep, get drunk, stun, and anesthesia, it is easy to swallow.
Iatrogenic factors (10%):
The dentures fall off during general anesthesia, the dental molds fall off when the teeth are inserted, and the sleeves fall off when the tubes are inserted.
1. Individual factors: common causes of foreign body esophageal foreign body: A. Insufficient diet or lack of concentration when eating, so that fish bones, chicken bones, meat bones are swallowed into the esophagus; B. dentures are too loose, food is too sticky Or the oral mucosa feels diminished, the denture is detached, and the food enters the esophagus; C. The degree of awakening is low when sleeping, the denture is detached, and the esophagus is swallowed; D. The small nuclei doped in the food, the bone spur is swallowed into the esophagus; The esophagus itself has stenosis, sputum and other diseases; F. swallowing dysfunction, pharyngeal sensation diminishes and causes swallowing; G. bad labor habits, such as woodwork, shoemakers or decorators, nails, screws, etc. are included in the mouth, not Ingestion with caution; H. Anesthesia is not awake, coma or mentally ill patients, may be swallowed when unconsciousness; attempted suicide.
2. Types of foreign objects: various foods, fruit cores, coins, toys, etc. Any substance that can enter the mouth may become a foreign body. Usually, the foreign body of the esophagus is divided into four types: animal type, plant type, metal type and chemical type. Most people reported that animal-type foreign bodies were mostly. Nandi reported that animal foreign bodies were 84%. Due to different food types in different countries and regions, cultural habits varied greatly, and the types and proportions of esophageal foreign bodies were different. In the same way, in the north of China, jujube nucleus and bone are common. In the south along the Yangtze River, fish bones, shrimps and shells are the main ones. Foreign reports are most common with bones, needles, coins and dentures.
Huge foreign bodies are more common in suicide attempters. These foreign bodies are mostly metal-type foreign objects, such as watches, small wrenches, and blades.
Prevention
Prevention of foreign body in the esophagus
Prevention of esophageal foreign bodies should pay attention to the following points:
1. Avoid eating in a hurry, and chew slowly.
2. The denture of the elderly should be strictly prevented from falling off. Before eating, be careful. Before going to bed, remove it before general anesthesia. The dentures should be repaired in time.
3. Educate children not to put all kinds of objects in the entrance to play.
4. Immediately seek medical attention after the foreign body has entered the esophagus. Do not use rice balls, leeks, taro, etc. to swallow, so as to avoid complications and difficulty in surgery.
Complication
Esophageal foreign body complications Complications, abscess, chronic mediastinal inflammation
The occurrence of complications of esophageal foreign body is related to the sharpness, size, swallowing process, foreign body retention site and tolerance of the foreign body. Generally, the person who has been infected with foreign body for 24 hours is more common in adults, less common in children, and some statistics on esophageal foreign body disease. The relationship between complications and complications, the incidence of esophageal foreign body complications is 3% to 7%, and the mortality rate is less than 1%. The complications are usually divided into esophageal complications, extra-oesophageal complications and respiratory complications. The most common of these are intra-esophageal complications, the most dangerous of which is large blood vessel rupture and bleeding in extra-esophageal complications.
Esophageal complications
Such complications include esophagitis, Zenker's diverticulum, esophageal scarring, etc., most common with esophagitis, long-term compression of foreign bodies or mucosal abrasion caused by sharp foreign bodies, can cause secondary infection, evolve into esophagitis Other complications, pain is persistent, mild systemic symptoms, local mucosal redness and swelling under esophagoscopy, severe erosion, ulcers, and Zenker chambers are mostly caused by long-term retention of coin foreign bodies. If not infected, there is no special clinical. Symptoms, most of these cases are X-ray or esophagoscopy. Most of the esophageal scar stenosis is the sequela of severe esophageal infection. The main symptoms are long-term persistent obstruction and dysphagia. Even if the foreign body is removed, the symptoms persist. Antibiotics The treatment is invalid.
2. Extra-esophageal complications
Such complications include perforation of the esophagus, inflammation around the esophagus, abscess around the esophagus, mediastinal inflammation and abscess, rupture of the common carotid artery, perforation of the thoracic aorta, aortic arch pseudoaneurysm, pericarditis, peritonitis, retropharyngeal abscess, cervical osteomyelitis, Pneumothorax, foreign body perforation injury, etc., which is the most common complication of esophageal perforation, the symptoms of esophageal perforation are aggravated, the degree is related to the location and size of the perforation, usually the small perforation of the cervical esophagus is lighter, and vice versa The large perforation is more serious. If the perforation of the lower esophagus may have abdominal pain, muscle tension and other abdominal irritation symptoms, the systemic reaction is heavier. Since the gas can be inserted into the esophagus around the perforation, the X-ray image can be used. It is observed that there is gas around the foreign body and the esophagus, the mediastinum is widened, and mediastinal emphysema occurs. Therefore, the diagnosis of esophageal perforation mainly relies on X-ray imaging examination, and strives for early diagnosis and early treatment, no later than 24 hours, in order to accurately determine the perforation site, Lipiodol or a water-soluble contrast agent shows perforation, and several common and dangerous complications are highlighted below.
(1) inflammation around the esophagus and abscess: it is the most common complication of esophageal foreign body, more common in pointed, rough irregular foreign body or foreign body incarcerated in the esophagus for a long time, causing inflammation around the esophagus is mainly Small and shallow esophageal perforation, foreign body penetrates the submucosa or muscle layer, forming secondary confinement cellulitis around the esophagus, but also due to severe esophageal wall inflammation outreach, X-ray shows the esophagus There are inflammatory swelling shadows, patients often have progressive local pain and dysphagia. The foreign body in the neck has tender points in the neck. If the abscess is formed, the neck is swollen, the tenderness is obvious, and the inflammatory mass can be touched. Some patients are involved. The trachea can cause difficulty breathing.
(2) mediastinal inflammation and abscess: generally sharp foreign body piercing too deep and secondary infection, cervical foreign body can form cellulitis and abscess in the deep neck, inflammation can also spread down to the upper mediastinum, and develop into mediastinal inflammation And abscess, esophageal thoracic perforation is more likely to develop into mediastinal inflammation and abscess, the clinical symptoms of mediastinal inflammation and abscess are severe pain in the back of the sternum, hyperthermia and systemic poisoning symptoms, and even toxic shock, X-ray imaging shows a significant increase in mediastinum Wide, increased density behind the sternum, some patients can see the abscess level and liquid pneumothorax, etc. For poor development, CT scan can be performed to show the lesion, the mediastinal abscess can be as high as 30% to 55%, incarcerated in Foreign bodies in the thoracic esophageal aortic arch and bronchial decentralization should be highly vigilant to prevent this complication.
(3) Large blood vessel rupture and hemorrhage: large blood vessel rupture and hemorrhage caused by esophageal foreign body, the most common aortic arch rupture, followed by left subclavian artery, common carotid artery, descending aorta and pericardium, foreign body penetrating into the adjacent esophagus Large blood vessel wall, or secondary infection, causes the blood vessel wall to be necrotic and erosive, forming a pseudoaneurysm or esophageal artery spasm. Patients often have fatal bleeding. In the early stage of the disease (about 7 days of esophageal foreign body), there is repeated small amount of hematemesis or blood in the stool. If the foreign body is incarcerated in the upper chest or neck esophagus and there is bleeding, the possibility of large blood vessel damage should be highly suspected. Active measures should be taken. Once the diagnosis is made, it is usually unnecessary to perform esophagoscopy or aortic angiography to avoid arterial rupture. Major bleeding, for those with pre-existing hemorrhage, should seize the opportunity to open the chest to explore, timely repair of blood vessel perforation, in order to save lives.
(4) tracheal-esophageal fistula: thoracic esophageal perforation can penetrate the tracheal wall to form tracheal-esophageal fistula, some patients may have esophageal stricture or esophageal diverticulum, but clinically rare.
3. Respiratory complications
Such complications are caused by reflux of liquid or food residue in the esophagus into the trachea, causing a series of symptoms, the most common are bronchitis, atelectasis, aspiration pneumonia and lung abscess, etc., patients may have cough, Symptoms such as fever and difficulty in breathing, physical examination revealed pulmonary voice, lung lobular consolidation, etc. X-ray filming revealed signs of thickening of the lungs, flaky blurring or lobular atelectasis.
Symptom
Symptoms of foreign body in the esophagus Common symptoms swallowing pain, difficulty swallowing, difficulty breathing, post-sternal pain, abscess, runny food, mistaken into the airway
The clinical features of esophageal foreign bodies are related to the location, size and nature of foreign bodies. Most patients have symptoms after esophageal foreign body, but Boyd statistics have about 10% without any symptoms. Usually the severity of symptoms and the characteristics of foreign bodies, parts and The extent of damage to the esophageal wall is related to the presence or absence of foreign bodies in the esophageal wall. The main clinical features are as follows:
Dysphagia
Dysphagia is related to the degree of esophageal obstruction caused by foreign bodies. Patients with complete obstruction have difficulty in swallowing, fluid is difficult to swallow, and nausea and vomiting occur immediately after swallowing. For those with smaller foreign body, they can still enter a fluid or semi-liquid diet. Individual patients have difficulty swallowing, even without any symptoms, and can be delayed for several months or years.
2. Foreign body obstruction
When a foreign body accidentally enters the esophagus, it usually begins to have a gas cap, followed by a foreign body obstruction in the esophagus. If the foreign body is in the esophagus of the neck, the symptoms are more obvious. The patient can usually point out the foreign body in the upper sternal fossa or the lower neck. If the foreign body is in the thoracic esophagus, there is no obvious obstruction, or only the sternal hinderal foreign body obstruction and dull pain.
3. Pain
The upper esophageal pain is most prominent, often located in the center of the neck. When swallowing, the pain is aggravated or even can not be turned; the middle esophagus pain can be behind the sternum, sometimes radiating to the back, the pain is not serious; the lower esophagus pain is lighter, can cause upper abdominal discomfort Or pain, pain often indicates the extent of esophageal foreign body damage to the esophageal wall. Heavier pain is a signal of foreign body damage to the esophageal muscle layer, which should be taken seriously. Usually the smooth foreign body is dull pain, the sharp edge and the tip foreign body are severely sharp. The esophageal mucosal injury is often persistent pain, and it is aggravated with the swallowing movement. Sometimes the most severe pain can indicate the resting part of the foreign body, but the accuracy of its positioning is very limited.
4. Increased sputum
Increased sputum is a common symptom, cervical esophageal foreign body is more obvious, if there is serious injury, bloody sputum can also occur. In all patients, the symptoms of increased sputum in children are obvious and more common, resulting in increased sputum. The reason is the combined effect of swallowing pain, dysphagia and esophageal occlusion. Local stimulation of foreign body can also increase secretion. Generally, according to the symptoms of increased sputum, combined with the history of foreign body, it can be preliminarily concluded that foreign body remains in the cervical esophagus but not in the thoracic esophagus. .
5. reflux symptoms
Reflux symptoms may occur after the foreign body remains in the esophagus. The reverse flow rate depends on the degree of foreign body obstruction of the esophagus and the infection of the tissue structure around the esophagus. Individual patients may also have reflex vomiting.
6. Respiratory symptoms
Mainly manifested as difficulty breathing, cough, cyanosis, etc., mostly occurs in infants and young children, especially in the upper part of the esophagus and upper esophagus, foreign bodies with large foreign bodies or sharp thorns, can press the throat or damage mucosa to cause inflammation.
The aspiration of the vomit or the foreign body stabs the throat, the wall of the trachea, and some foreign bodies are repelled from the esophagus to the trachea, forming a so-called migratory foreign body. Jackson believes that the foreign body causes lung symptoms such as cough, cyanosis, and difficulty in breathing. : 1 secretion reflux aspiration; 2 foreign body is huge, oppress the tracheal wall; 3 foreign body causes infection of adjacent tissues, spread to the larynx and trachea; 4 esophagus - tracheal fistula.
7. Clinical differences
Due to the individual differences of different patients, the characteristics of medical history and the types of foreign bodies are different, and their clinical manifestations vary widely. The long-term retention of foreign bodies often leads to adverse consequences. Even if the foreign body is round and smooth, it can cause congestion and swelling of the mucosa of the esophageal wall. , the formation of granulation, resulting in increased difficulty in swallowing, if it is a sharp foreign body, the longer stay time is more likely to occur around the esophageal infection and erosion of large blood vessels, because the patient's tolerance is not the same, so can not judge the severity of the symptoms alone, but also Combined with other factors, especially the type of foreign body, the stimuli of the resting part and the foreign body, etc., in addition, individual patients may have obvious initial symptoms, and then the symptoms disappear due to the foreign body falling into the stomach, but it is likely that there is foreign matter retention for clinical judgment. Don't neglect because you can still eat.
According to statistics, 10% of patients have delayed treatment due to small foreign body and obvious symptoms.
Examine
Examination of foreign bodies in the esophagus
1. Imaging examination
Imaging examination is an effective auxiliary examination to determine whether there are esophageal foreign bodies and foreign body staying parts.
(1) X-ray inspection:
X-rays have a decisive diagnostic significance for opaque foreign objects such as metallic foreign bodies, but some thin bone fragments can not be seen in perspective due to poor development or small volume, then X-ray positive, lateral filming It is worth noting that there have been reports in the literature that the localized ossification of thyroid cartilage and ring cartilage has been misdiagnosed as bony foreign body.
For foreign bodies whose X-rays are not developed at all, a small amount of barium angiography can be used for X-ray examination to show foreign matter, or to observe the presence or absence of barium retention, and the presence of foreign matter can be indirectly judged. The barium angiography method has direct ingestion. Tincture, swallowing sac or sputum, etc., as a white medicine, if a large amount of retention on the surface of foreign bodies, not only hinder the observation of esophagoscopy, but also affect the removal of foreign bodies, generally should be avoided, for those suspected of perforation of esophagus, Disinhibition of barium angiography advocates the use of water-soluble contrast agents for development, which has the advantage of being thin and self-absorbable.
Some indirect radiographic signs contribute to the diagnosis of foreign bodies, such as swelling of the anterior soft tissue, tracheal and esophageal displacement, Zenker's diverticulum, upper mediastinum widening, etc. The most common initial radiological changes in esophageal perforation are esophagus. There is gas around.
(2) CT examination:
The good imaging effect on X-ray translucent foreign objects has increased its application prospects. Kobayash used CT scan to examine a 13-month-old male infant. No X-ray examination showed no foreign body shadow. When a button was found to have foreign objects, it was reported in the literature that the CT scan is most suitable for long-term X-ray translucent foreign matter, which can clearly show the contour of the foreign body. It has been reported in the literature that 7 cases of conventional X-ray film negative were examined by CT scan. Three cases were found to be fish bones or fish bones, which indicates that CT scan is more valuable for detecting small foreign bodies in the esophagus than conventional X-ray examination.
2. Esophagoscopy
Esophagoscopy, including rigid metal esophagoscopy and fiber esophagoscopy, is the most reliable diagnostic method. The esophagus can be enlarged due to nausea or vomiting. Some pointed foreign bodies such as jujube can fall off. While swallowing into the stomach, the foreign body remains in the esophagoscopy, but if there is local damage or congestion and swelling of the esophagus, there is a foreign body retention. Usually, the foreign body type seen under the esophagus is obstructive, piercing and Hybrid type, when foreign matter is found, it is taken out, but in infants and young children, when the esophagus is inserted, the child has obvious difficulty in breathing. At this time, although the foreign body has not been seen for one-time removal, the esophagoscope should be removed immediately. Intubation or tracheotomy is performed. After the dyspnea is relieved, the esophagus is inserted into the esophagus to remove the foreign body. A small number of cases are buried foreign bodies, and the inflammatory granulation is deeply buried in the esophageal wall due to long-term retention of foreign bodies. Down, or hidden in the Zenker chamber, making it difficult for the examiner to detect foreign objects. For such patients, in addition to careful examination, CT scans can be performed, and surgical exploration is possible if necessary. Confirmed.
Diagnosis
Diagnosis and identification of foreign bodies in the esophagus
Medical history analysis
The history of swallowing foreign bodies is very important for diagnosis. Some people think that the esophageal foreign body can be initially diagnosed based on medical history and symptoms. The correctness is sometimes more reliable than X-ray filming. Any patient has a history of esophageal foreign body disease, and later dysphagia, pain or Other symptoms, that is, foreign bodies should be suspected.
There are clear history of foreign body and different degrees of esophageal foreign body symptoms. Experienced clinicians can judge the presence and location of foreign bodies according to this, but infants and young children can not directly state and express their symptoms, plus feeding liquid food (milk, etc.) It is easy to pass through the foreign body, so there is no difficulty in swallowing or delay in diagnosis due to respiratory symptoms. When some infants appear to refuse food, the sputum suddenly increases, vomiting is unexplained after eating, irritability, grasping the neck with hand, etc. This disease should be thought of.
To collect the history of foreign bodies, you should pay attention to the following questions:
(1) Foreign body type: Sharp esophageal foreign body is easy to puncture and tear the esophageal mucosa, and even the esophagus can cause perforation of the esophagus. Only the puncture mucosa is also perforated due to the formation of intramural abscess; huge foreign body can also cause esophageal tear. Long-term corrosion of smooth foreign objects can cause secondary perforation.
(2) Strong swallowing factor: After swallowing foreign bodies, the patient almost has a history of trying to swallow food to force foreign matter into the stomach. If the foreign body fails to enter the stomach, it will increase the chance of perforation of the esophagus.
(3) Foreign matter retention time: foreign matter is embedded or invaded in the esophagus, and remains for a long time. The esophageal wall may be perforated due to foreign matter corrosion and secondary infection.
(4) Symptom development factors: rapid development and aggravation of clinical symptoms often suggest that esophageal rupture and perforation may occur.
Physical examination
(1) Drinking water check-up method: for the examination of pointed foreign bodies incarcerated in the neck esophagus, the patient can drink water during the examination, the patient has dysphagia and facial pain expression has diagnostic significance, if the pointed foreign body has penetrated In the esophageal wall, if the above symptoms are aggravated and the inflammation of the neck is swollen, it should not be checked by this method to prevent the swallowed water from flowing out of the esophagus or into the trachea.
(2) The neck examination method is located in the esophageal foreign body in the neck, and the corresponding part has a fixed tender point. The pain is increased when the neck is turned, and there is tingling, oppression and compression when the anterior border of the sternocleidomastoid muscle is pressed to the side of the esophagus. Moving the trachea also has pain or exacerbates the pain. These phenomena are very important for the diagnosis of cervical esophageal foreign bodies, especially sharp foreign bodies.
Concomitant cervical peri-esophageal inflammation, peripheral abscess, visible skin swelling in the vicinity of the anterior cervical sternocleidomastoid muscle, can touch subcutaneous emphysema and mass, etc. For the middle and lower part of the esophagus, only the complication occurs Physical examinations are important, and generally no positive signs.
