Esophageal diverticulum
Introduction
Introduction to the esophagus The diverticulumofoesophagus is also known as Zenker's diverticulum in clinical practice. It refers to the saclike protrusion that communicates with the esophagus, and its classification is complicated. According to the location of the disease, it can be divided into pharyngeal esophageal diverticulum, middle esophageal diverticulum and supracondylar esophageal diverticulum. According to its pathogenesis, it can be divided into traction, internal pressure and traction internal pressure diverticulum. According to the structure of diverticulum wall, it can be divided into true diverticulum. (containing the full layer of the esophageal wall) and pseudodural diverticulum (the muscle layer lacking the esophageal wall). In addition, it can be divided into congenital diverticulum and acquired diverticulum. basic knowledge The proportion of illness: 0.02% Susceptible people: no specific population Mode of infection: non-infectious Complications: dysphagia, malnutrition, pneumonia, atelectasis, lung abscess
Cause
Esophageal diverticulum
Muscle movement disorder (30%):
The pharyngeal esophageal diverticulum is often not caused by a single factor, mostly due to dysregulation of the pharyngeal muscles and esophageal muscles, achalasia or other motor abnormalities, which cause mucosal bulging on the above anatomical basis to form a diverticulum.
Food stimulation (20%):
A very small number of pharyngeal esophageal diverticulum cancers may be caused by long-term food and secretion stimulation. Patients habitually press the diverticulum to facilitate diverticulum emptying, which may also be a cause of cancer. If the wall of the iliac crest is irregular during the angiography, the sputum cancer should be highly suspected and further examination is needed.
Lymph node inflammation (20%):
The diverticulum of the middle esophagus can be bulging or pull-out type, most of which are the pull-out type diverticulum. The etiology and performance of the dilated esophageal diverticulum and the supraorbital diverticulum are completely similar, while the pull-out type diverticulum is due to inflammation of the parabronchial lymph nodes or tuberculosis. Caused by scar traction, it has a full-thickness tissue of the esophagus, including the mucosa, submucosa and muscle layers, and the neck is narrow and narrow like a tent. The pull-out type diverticulum occurs mostly in the anterior and right wall of the esophagus at the bifurcation of the trachea. Some authors believe that a part of the esophageal diverticulum that is unrelated to abnormal esophageal movement is a congenital intestinal cyst or esophageal duplication.
Pathogenesis
The mechanism of esophageal diverticulum has been controversial. Zenker's diverticulum has always been thought to be caused by dysregulation of the pharyngeal and upper esophageal muscles. Knuff and other specially designed pressure recording systems have studied 9 cases of Zenker's diverticulum and 15 cases of no esophageal disease. The control, but did not find evidence of inconsistent activity of the pharynx and upper esophageal muscles, recently Cook et al. 14 cases of Zenker's diverticulum case and 9 controls were simultaneously studied using TV fluoroscopy and manometer, embedded in the pressure catheter The signs of the transmission line recorded the contraction and relaxation activities simultaneously at different locations and at different times. It was found that there was no difference between the diverticulum patients and the control subjects. Compared with the control, the upper esophageal sphincter relaxation was normal in the diverticulum, but the maximum open scale Significantly reduced, it is believed that this diverticulum is reduced by the opening of the upper esophageal sphincter, thereby increasing the pressure of the inferior vagina, so that the diverticulum is formed, not caused by the inconsistency of the pharyngeal esophageal muscles or the abnormal sphincter relaxation. The middle esophageal diverticulum is mostly caused by inflammation and adhesion around the esophagus. Therefore, it is a traction type, with tuberculosis, and can also be seen in patients with scleroderma. Accompanied by esophageal hiatus hernia, may be related to reflux esophagitis, the pseudo-diverticulum in the esophageal wall is mostly due to submucosal gland inflammation, inflammatory cells infiltrating the gland, causing gland obstruction, expansion and formation of capsular bags, so multiple In the esophageal fistula, gastroesophageal reflux and candidiasis, Watarai and other recent reports, there are cases of congenital esophageal wall pseudo-diverticulum.
Prevention
Esophageal diverticulosis prevention
There is no effective preventive measure for this disease. Therefore, when there are suspicious symptoms mentioned above, it should be checked in time to achieve early detection, early diagnosis and early treatment. Go to bed early and get up early and exercise. Insufficient sleep can reduce the body's immune function, and it is also easy to stimulate the fire, causing external injuries. Keep your mind calm. Avoid anger in the spring, do not be too impatient, always keep your peace of mind, quit smoking, drink less alcohol and coffee. Smoking is the most vulnerable to damage to the respiratory surface barrier and induces disease onset.
Complication
Esophageal diverticulum complications Complications, dysphagia, malnutrition, pneumonitis, atelectasis
Due to the accumulation of food, the diverticulum will continue to increase and gradually fall, which is not conducive to the discharge of the accumulators in the diverticulum. As a result, the opening of the diverticulum is facing the lower part of the throat. The swallowed food first enters the diverticulum and returns to the flow. Difficulties, and progressive progressive, some patients also have bad breath, nausea, loss of appetite and other symptoms, some due to eating difficulties and malnutrition and weight loss, in the absence of treatment, if the diverticulum gradually increased, accumulated food And secretions begin to increase, sometimes automatically return to the oral cavity, occasionally causing aspiration, the result of aspiration will lead to pneumonia, atelectasis or lung abscess and other complications, bleeding, perforation complications are less common.
Symptom
Esophageal diverticulum symptoms Common symptoms Cacao between the airway and the esophagus, the fistula of the fistula, foreign body sensation, inflammation, atelectasis, dyspnea, nausea
In the early stage, there was only a small part of the mucosa with prominent mucosa. The opening was large, and it was connected to the right angle of the pharyngeal esophagus. The food was not easy to remain. It can be asymptomatic or mild. Only occasionally the food sticks to the wall of the diverticulum. It is itchy throat. Stimulating symptoms, when the cough or water food residue falls off, the symptoms disappear.
If the diverticulum gradually increases, the accumulated food and secretions begin to increase, sometimes automatically returning to the mouth, occasionally causing aspiration. During this time, the patient can hear the sound in the pharynx due to air and food entering and leaving the diverticulum.
Due to the accumulation of food, the diverticulum will continue to increase and gradually fall, which is not conducive to the discharge of the accumulation of the chamber, so that the opening of the diverticulum is facing the lower part of the throat. The swallowed food first enters the diverticulum and returns to the flow. Difficulties, and progressive progressive, some patients also have bad breath, nausea, loss of appetite and other symptoms. Some suffer from malnutrition and weight loss due to eating difficulties.
Clinical manifestations of the upper chamber:
Most patients with small sacral diverticulum can have no symptoms or mild symptoms. The diverticulum with motor dysfunction can have different symptoms, such as mild indigestion, post-sternal pain, upper abdominal discomfort and pain, bad breath, nausea, chest. There are often squeaking sounds, etc., huge sputum on the upper chamber to oppress the esophagus can cause difficulty in swallowing, and reflux causes aspiration.
Clinical manifestations of the middle esophagus diverticulum:
Most of the pull-out type diverticulum is small and the neck width is narrow, which is good for drainage and is not easy to cause food residue. Therefore, there is generally no symptom, which is often found in a healthy physical examination or in the absence of a change, and has not changed for many years. Dysphagia and pain occur only when the esophagus is pulled or deformed, and inflammation occurs in the diverticulum. If the diverticulum inflammation, ulcers, necrotic perforation, can cause bleeding, mediastinal abscess, bronchospasm and other complications and corresponding symptoms and signs.
Clinical manifestations of pseudo-esophageal diverticulum:
Patients often complain of mild dysphagia, with intermittent or slow progression of symptoms. Esophageal pseudo-diverticulum is more common in the five or sixty-year-old age group, more men than women.
Examine
Esophageal diverticulum examination
1. X-ray swallowing inspection
Since the small diverticulum may be covered by the esophagus filled with tincture, the body position should be observed for detailed observation. Zenker's diverticulum is generated on the left side wall. Therefore, the left oblique position is easy to find. If the head is turned to the left, it is easier to display. The early diverticulum was bulging in a half-moon shape. The later diverticulum was spherical, hanging in the mediastinum. The diverticulum was able to compress the esophagus. When there was food residue in the diverticulum sac, there was a filling defect and the mucous membrane was rough and disordered. The diverticulum in the middle esophagus was funnel-shaped. The shape of the tent or the smooth bulge of the tent, the upper esophageal diverticulum is single, a few are double-haired, more than three diverticulum is very rare, X-ray examination of the esophageal diverticulum is characteristic, not easy to be confused with other diseases.
2. Endoscopy
Special care should be taken when examining Zenker's diverticulum patients. Because it can be inserted into the capsule, perforation can be caused. The middle esophagus diverticulum is often firstly found by gastroscopy. The gastroscope can not only find the size of the diverticulum, but also accurately observe the presence or absence of erosion in the wall. , bleeding, ulceration or cancer, the choice of treatment can help.
Diagnosis
Diagnosis and diagnosis of esophageal diverticulum
diagnosis
The diagnosis can be confirmed based on the patient's medical history, clinical symptoms, and laboratory tests.
Diagnostic and diagnostic criteria for the pharyngeal esophageal diverticulum: There are not many positive signs of clinical physical examination. Some patients repeatedly squeezing the anterior border of the sternocleidomastoid muscles after swallowing a few mouthfuls of air, and the sound can be heard. The main method of diagnosis is X-ray examination. Occasionally, the liquid level is seen on the plain film. The diverticulum can be seen behind the esophagus. If the diverticulum is obviously pressed against the esophagus, it can be seen that after the expectorant enters the diverticulum, another tincture shadow flows from the chamber to the lower chamber. esophagus. Repeated changes in body position during angiography are conducive to the filling and emptying of the diverticulum. It is easy to find the small diverticulum and observe whether the mucosa in the sputum is smooth, except for early malignant transformation.
The middle esophagus diverticulum is also diagnosed by X-ray. When the sputum angiography is performed, the supine position or the low head position should be used, and the position should be rotated left and right to clearly show the contour of the diverticulum. Because the opening of the diverticulum in the middle esophagus is relatively large, the contrast agent is very It is easy to flow out of the chamber and is not easy to stay in the memory.
Diagnostic and diagnostic criteria for pseudo-esophageal diverticulum: false diverticulum can not be found on X-ray examination. Long-necked flasks or small button-shaped pouches with multiple hairs can be found in the esophageal lumen, ranging from 1 to 5 mm. There are scattered or limited distribution, obvious narrow esophagus, and more false diverticulum, so it is considered that esophageal stricture is related to inflammation around the pseudo-diverticulum.
Differential diagnosis
Suppurative esophagitis
Suppurative esophagitis is the most common mechanical damage caused by foreign bodies. The bacteria multiply in the esophageal wall, causing local inflammatory exudation, different degrees of tissue necrosis and pus formation, and also a wide range of cellulitis.
2. Esophageal tube
Patients with esophageal tuberculosis generally have pioneering symptoms of tuberculosis in other organs, especially tuberculosis. The symptoms of the esophagus are often confused or concealed by other organ symptoms, so that they cannot be discovered in time. According to the pathological process of tuberculosis, the early stage of infiltration may have fatigue and low fever. Symptoms of poisoning such as increased erythrocyte sedimentation rate, but also symptoms are not obvious, followed by swallowing discomfort and progressive dysphagia, often accompanied by persistent throat and sternal pain, aggravation when swallowing, ulcerative lesions mostly swallowed Pain is characteristic of it. Food spilling into the trachea should consider the formation of tracheal esophageal fistula. Difficulty in swallowing suggests that fibrosis of the lesion causes scarring.
3. Fungal esophagitis
The clinical symptoms of fungal esophagitis are atypical. Some patients can have no clinical symptoms. Common symptoms are swallowing pain, difficulty in swallowing, upper abdominal discomfort, post-sternal pain and burning sensation. It can radiate to the back like angina. Candida esophagitis can cause severe bleeding but is uncommon. Untreated patients may have epithelial shedding, perforation and even disseminated candidiasis. Esophageal perforation can cause mediastinal inflammation, esophageal fistula and Esophageal stricture, patients with persistent high fever granulocytopenia should be checked for skin, liver, spleen, lung and other disseminated acute candidiasis.
4. Viral esophagitis
HSV infection of the esophagus often has herpes and nasal herpes. The main symptom is swallowing pain. The pain is often aggravated when swallowing food. The food is slow in the esophagus after swallowing. A few patients have difficulty in swallowing. The minor infection can be Asymptomatic.
