Esophageal injury
Introduction
Introduction to esophageal injury Esophageal injury is a disease caused by rupture of the esophagus and perforation as the main disease caused by instruments or foreign bodies. If not treated in time, acute mediastinal inflammation, esophageal pleural palsy, and possibly death may occur almost without exception. The esophagus can be damaged by many different reasons. According to the cause of the injury, it can be divided into mechanical damage and chemical damage. Mechanical damage can be divided into intraluminal damage and extraluminal damage. Symptoms and signs of esophageal injury caused by different causes are different. The location and size of the perforations are different. The time from perforation to visit is different, and the clinical manifestations are different. In either case, about 90% to 97% of patients have severe pain in the neck or sternum, which is exacerbated when swallowed. 31% had difficulty breathing, increased heart rate, decreased blood pressure, and even shock. Surgical or non-surgical treatment can be used after esophageal injury. Its purpose is to prevent further contamination of surrounding tissues from the breach, to remove existing infections, to restore the integrity and continuity of the esophagus, and to restore and maintain nutrition. basic knowledge The proportion of sickness: 1.4% Susceptible people: no special people Mode of infection: non-infectious Complications: peritonitis
Cause
Causes of esophageal injury
The esophagus can be damaged by many different reasons. According to the cause of the injury, it can be divided into mechanical damage and chemical damage. Mechanical damage can be divided into intracavitary injury and extraluminal injury. In recent years, with esophagus The number of cases diagnosed and treated by intracavitary instruments is rapidly increasing. The proportion of iatrogenic esophageal injury in these diseases is also increasing without disease. In addition, the esophageal injury is divided into cervical esophageal injury and thoracic esophageal injury. And abdominal esophageal damage.
Intracavitary injury (26%):
The use of intraluminal medical devices for the diagnosis and treatment of esophageal diseases is fairly safe today, but not entirely without risk. Esophageal injuries often occur during the diagnosis and treatment of these devices in the esophagus or through the esophagus. The complications of hard esophagoscopy are higher than those of fiber esophagoscopy. In patients with supraorbital diverticulum, achalasia, and esophageal stricture, esophageal injury is more likely to occur if not handled carefully.
Other injuries (22%):
The esophagus can be damaged by a variety of different reasons. According to the cause of the injury, it is roughly divided into mechanical damage and chemical damage. In recent years, the number of cases diagnosed and treated with instruments in the esophageal lumen has increased rapidly, and iatrogenic The proportion of esophageal injuries in these diseases is also increasing. In addition, according to the site of esophageal injury, it is divided into cervical esophageal injury, chest esophageal injury and abdominal esophageal injury.
Extraluminal injury (20%):
Extraluminal injuries are mainly due to chest or neck contusions or penetrating gunshot wounds, knife wounds, and more often with other injuries to the chest or neck.
Pathogenesis
The serosal and submucosal layers in the intestinal structure contain anti-tension collagen and elastic fibers. Since the esophagus has no serosal layer and is different from other parts of the digestive tract, it is more susceptible to damage, and the posterior wall of the esophagus is covered with a layer of mucosa. Very thin fibrous membrane, the middle section is only covered by the right pleura, the lower section is covered by the left pleura, there is no soft tissue support around, and the normal intrathoracic pressure is lower than atmospheric pressure. These are the anatomical factors that the esophagus is easily damaged, and the instrument is used in the esophagus. The complications of endovascular examination and treatment are mainly perforation of the esophagus. The perforation of the esophagus is the cervical esophagus at the junction of the pharyngeal muscle and the pharyngeal sphincter. About 50% of the esophageal perforation occurs in the Lanniers triangle of the pharynx. The pharyngeal sphincter and the pharyngeal muscle at the level of the cervical vertebrae 5 and 6, when there is a neck spur and neck overextension, it is easy to be perforated by the injury. The second part of the esophageal injury that causes the esophageal injury is the upper esophagus. Relatively narrow, some of the same hilar, aortic arch and left main bronchus fixed, other vulnerable parts are the distal end of the esophagus and the stomach, as well as obstructive lesions In the proximal segment, the site where the esophageal cancer extends and the site where the examination or expansion is performed.
After the perforation of the esophagus, a large amount of bacteria in the mouth swallowed with saliva, and the acidity of the stomach is very strong. Under the action of the negative pressure of the chest, the contents of the stomach are more likely to flow into the mediastinum through the perforated area, resulting in infection of the mediastinum and corrosion of the digestive juice. Can penetrate the mediastinal pleura into the chest, causing suppurative inflammation in the chest.
Prevention
Esophageal injury prevention
Strengthen nutrition and use foods that are easy to digest, contain enough calories, protein and vitamins. Such as porridge, milk, soft rice, soy milk, eggs, lean meat, fresh vegetables and fruits rich in vitamins A, B, C. These foods can enhance the body's resistance.
Complication
Esophageal injury complications Complications peritonitis
Can be complicated by purulent inflammation in the chest, peritoneal inflammation.
Symptom
Symptoms of esophageal injury Common symptoms Subcutaneous emphysema, traumatic chest pain, chest pain when swallowing
Symptoms and signs of esophageal injury caused by different causes are different. The location and size of the perforations are different. The time from perforation to visit is different, and the clinical manifestations are different. In either case, about 90% to 97% of patients have severe pain in the neck or sternum, which is exacerbated when swallowed. 31% had difficulty breathing, increased heart rate, decreased blood pressure, and even shock. Almost all of the mediastinal or lower neck subcutaneous emphysema, the latter is a mediastinal abscess or pus pneumothorax. More than 87% to more than 90% of cases have fever, and white blood cell counts increase.
1, cervical esophageal perforation
Neck esophageal perforation often occurs in the thin posterior wall of the esophagus, and the anterior fascia attached to the esophagus can limit the spread of contamination to the side. In the first few hours of perforation, there is no inflammatory manifestation in the neck. After a few hours, the oral or gastric fluid passes through the perforation into the posterior esophageal space and extends into the mediastinum along the plane of the esophagus, causing inflammation of the mediastinum. The patient complains of neck pain, stiffness, and vomiting. Stomach contents and difficulty breathing. Physical examination revealed that the patient was at risk, with varying degrees of difficulty breathing. Rough noise breathing through nasal breathing is usually heard. The palpation of the neck revealed a hard neck and a snoring sound due to subcutaneous emphysema. Symptoms of systemic infection often occur after 24 hours.
2, chest esophagus perforation
Unlike the neck perforation, the thoracic esophageal perforation directly causes mediastinal contamination, and rapid mediastinal emphysema and mediastinal inflammation occur. Although it is only mediastinal contamination in the early stage, it can rapidly develop into a necrotizing inflammatory process. When the thin mediastinal pleura is punctured by inflammation, the gastric juice and stomach contents are returned to the mediastinum and pleural cavity through the rupture, causing contamination and accumulation of the pleural cavity, forming a purulent inflammation of the mediastinum and pleural cavity. The upper middle esophageal perforation is often worn through the chest. This inflammatory process and massive accumulation of body fluids caused by perforation of the esophagus are clinically manifested as severe pain in one side of the chest, accompanied by aggravation during breathing and radiation to the scapular region. There are clear dysphagia in the perforation site, low blood volume, increased body temperature, increased heart rate, and increased heart rate is not proportional to the increase in body temperature. Symptoms of systemic infection and difficulty in breathing, depending on the severity of chest contamination, the amount of fluid pneumothorax, and the presence or absence of airway compression, vary in severity. Esophageal injury after mediastinoscopy is more difficult to diagnose, and sometimes the diagnosis of esophageal injury or perforation is made even when the patient develops mediastinal inflammation and subcutaneous emphysema or if the pathological report biopsy has esophageal mucosa or esophageal muscle. Physical examination can find that patients have different degrees of poisoning symptoms, do not dare to breathe hard, can hear the voice at the bottom of the lungs, when holding the breath, you can hear the mediastinum or snoring sounds with each heartbeat. The root of the neck or the front chest wall touches the subcutaneous gas. When the perforation breaks into the pleural cavity of one side, different signs of liquid pneumothorax appear. On the affected side, the upper part of the chest cavity is squeaking, the lower part is voicing, and the sick side breath sound disappears. A small number of cases can be developed with tracheal translocation, mediastinal compression of tension pneumothorax, inflammation of the mediastinum and thoracic cavity produces stimulation of the diaphragm, which can be expressed as abdominal pain, upper abdominal muscle tension, abdominal tenderness, should pay attention to the same acute abdomen Identification.
3, abdominal esophageal perforation
The injury of the esophageal abdominal cavity is less common. Once the injury, the gastric fluid enters the free abdominal cavity, mainly causing contamination of the abdominal cavity. The clinical manifestations are the symptoms and signs of acute peritonitis. This is similar to the gastro-duodenal perforation. It should be noted that the distal segment of the esophagus can also be manifested in this condition. Sometimes this contamination may not be in the abdominal cavity but in the posterior peritoneum, which will make the diagnosis more difficult. This is because the esophagus of the peritoneal cavity is adjacent to the diaphragm, and it is often characterized by pain in the upper abdomen and dull pain in the sternum and radiating to the shoulder.
Although these clinical manifestations of esophageal perforation, it is sometimes difficult to make an immediate diagnosis based on these non-characteristic symptoms and signs, often with the aid of other auxiliary examinations to confirm the diagnosis. And need to identify with other diseases such as stomach, duodenal ulcer perforation, pancreatitis, myocardial infarction, descending aortic aneurysm, pneumonia, spontaneous pneumothorax.
Examine
Esophageal injury examination
1, X-ray inspection
X-ray plain film examination was performed according to the location and cause of the perforation. The neck perforation can be found to contain gas in the neck fascia plane, the trachea is displaced, the posterior esophageal space is widened, and the normal cervical vertebrae curvature disappears. In some patients, gas-liquid level, neck or mediastinal emphysema, and pneumothorax and pneumoperitoneum can be found in the posterior esophageal space. When the chest esophagus is perforated, the mediastinum is widened, and there is gas or gas-liquid level in the mediastinum, and the gas is flat in the thoracic cavity. Free gas can be found under the perforation of the abdomen. With X-ray examination, about 12% to 33% of cases cannot show the X-ray signs suggesting esophageal perforation and are affected by the time after perforation.
2, esophagography
Many patients do not have typical symptoms at the time of presentation, but are characterized by severe dyspnea, hypotension, sepsis, shock, coma, or blurred acute abdomen or chest emergency. Therefore, patients with suspected esophageal perforation and general conditions are allowed to use esophagography to confirm the diagnosis of esophageal perforation in patients with common X-rays. Esophageal angiography is also used to determine the size and location of the perforation. Oral contrast agents under fluoroscopy can show the presence or absence of stenosis in the esophageal lumen, the perforation of the esophagus, and the distal end of the esophagus. The oral iodized oil-influencing agent has better effect and less irritation. If the elixir is leaked out of the esophagus, it is difficult to remove the surgery. Foley et al. introduced a water-soluble contrast agent first. If no gargle was seen, a tincture was added to further confirm the diagnosis. It should be noted that despite the use of contrast as a routine diagnostic tool, there is still a 10% false negative, so that esophageal perforation cannot be completely excluded when the contrast is negative.
3, fiber light guide esophagoscopy
It has important diagnostic value for chest trauma and foreign body-induced esophageal injury. When esophageal angiography is negative, sometimes the fiberoptic esophagoscopy can directly see the esophageal injury, and can provide accurate positioning to understand the pollution situation. The results of the esophagoscopy also contribute to the choice of treatment.
4, CT examination
Today's chest and abdomen CT examinations have been quite common. When the clinical diagnosis of esophageal injury and the X-ray can not prompt the exact diagnosis, further diagnosis includes CT examination of the chest or abdomen. For patients with "normal" esophageal angiography, diagnosis is based on medical history, physical examination, and CT findings. The diagnosis of esophageal perforation should be considered when CT imaging has the following signs: 1 There is gas in the mediastinal soft tissue surrounding the esophagus. 2 Close to the esophagus in the mediastinum or in the abscess of the chest. 3 The inflated esophagus communicates with a lumen adjacent to the mediastinum or mediastinum. Pleural effusion, especially the left pleural effusion, further suggests the possibility of perforation of the esophagus. Esophageal angiography should be performed when any of the above is underneath to affirm the diagnosis and determination of the site of the perforation, which is very important for guiding surgical treatment. In addition, the follow-up observation of the initial efficacy of the patient with CT is also a particularly effective method.
5, other
Because of the saliva, gastric juice and a large amount of digestive juice entering the chest cavity, patients with esophageal perforation have a pH of less than 6,0, and the amylase content is increased when the diagnostic thoracic puncture is performed. It is a simple and diagnostic significance. Methods. In patients with suspected esophageal injury, a small amount of methylene blue can be seen in the thoracic puncture fluid in the drain, which is also helpful for diagnosis.
Diagnosis
Diagnosis of esophageal injury
diagnosis
It can be diagnosed based on medical history, clinical symptoms and laboratory tests.
The complications and mortality after esophageal perforation are significantly related to the time from onset to diagnosis. Therefore, it is very important to make a rapid diagnosis of esophageal perforation in the early stage. For patients with pain in the neck, chest or abdomen after operation of the instruments in the esophagus, the possibility of esophageal perforation is thought to occur. There are Mackler's triads that are vomiting, lower chest pain, and subcutaneous emphysema in the lower neck. The possibility of perforation of the esophagus should be promptly suspected and should be further examined. Chest trauma, especially in patients with trauma near the esophagus, should be routinely checked for esophageal damage. When paying attention to and often thinking of the occurrence of this disease, combined with relevant medical history, symptoms, signs and necessary auxiliary examinations, timely and correct diagnosis can be made. A small number of cases were not diagnosed in time, until the empyema appeared in the later stage, and even the food was found in the chest or thoracic drainage.
Differential diagnosis
Attention should be made to distinguish between cervical esophageal perforation, thoracic esophageal perforation, and abdominal esophageal perforation.
