hard to swallow
Introduction
Introduction to dysphagia Dysphagia refers to the sensation of obstruction of the pharynx, sternum, or esophageal area from the oral cavity to the stomach. Swallowing is a complex reflex action. It is a contraction of the oropharyngeal voluntary muscles, relaxation of the esophageal sphincter, and rhythmic motility of the esophageal muscle. A series of sequential and coordinated movements that feed the fluid or group into the stomach. Inside, the swallowing action is dominated by high-level nerve centers such as medulla, and IX, X, and XII brain nerves are particularly important for swallowing. Dysphagia can be divided into two categories: mechanical and motor. basic knowledge The proportion of illness: 0.001% Susceptible people: no specific population Mode of infection: non-infectious Complications: Cardiac cancer Esophageal cancer Reflux esophagitis
Cause
Dysphagia
Oropharynx disease (20%):
Oropharyngeal inflammation (viral, bacterial), oropharyngeal injury (mechanical, chemical), pharyngeal diphtheria, pharyngeal tuberculosis, pharyngeal tumor, posterior pharyngeal wall abscess and other throat diseases can cause dysphagia, most of the otolaryngology treatment Afterwards, the swallowing sensation can be improved or relieved.
Esophageal disease (25%):
Esophagitis (bacterial, fungal, chemical), benign esophageal tumors (leiomyomas, lipoma, hemangioma, etc.), esophageal cancer, esophageal foreign body, esophageal muscle dysfunction (cardiac achalasia, diffuse esophageal fistula, etc.) ), extremely enlarged thyroid gland, etc., of which esophageal cancer is an important cause.
Neuromuscular disease (20%):
Medullary palsy, myasthenia gravis, organophosphate insecticide poisoning, polymyositis, dermatomyositis, pharyngeal achalasia and so on.
Other systemic diseases (20%):
Rabies, tetanus, botulism, iron deficiency dysphagia (Plummer-Vinson syndrome).
Pathogenesis
Swallowing is a complex reflex action. It is a contraction of the oropharyngeal voluntary muscles, relaxation of the esophageal sphincter, and rhythmic motility of the esophageal muscle. A series of sequential and coordinated movements that feed the fluid or group into the stomach. Inside, the swallowing action is dominated by high-level nerve centers such as medulla, and IX, X, and XII brain nerves are particularly important for swallowing. Dysphagia can be divided into two categories: mechanical and motor.
1. Mechanical dysphagia
Mechanical dysphagia refers to dysphagia caused by stenosis of the swallowed food cavity. The esophageal stenosis is dominant, the normal esophageal wall is elastic, and the lumen diameter can be expanded by more than 4 cm. Various inflammatory and obstructive diseases make it Difficulties in swallowing can occur when the lumen is limited. This type of dysphagia is common in the clinic. For example, after the chemical burn of the esophagus, the esophageal cavity is highly narrow and causes difficulty in swallowing due to scar formation. Due to infiltration of the cancer, the esophageal stenosis is blocked by the esophageal lumen, which is characterized by progressive dysphagia.
2. Sports dysphagia
Exercise dysphagia refers to difficulty in swallowing movements (initiation factors) and/or subsequent dysphagia caused by a series of reflex dysfunctions, including damage to the nerve center that governs swallowing movements and muscles involved in swallowing Qualitative damage or dysfunction, the most common are caused by various causes of bulbar palsy (ball paralysis), esophageal swallowing muscle paralysis.
Prevention
Dysphagia 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. Once you find this symptom, you should go to a regular hospital as soon as possible to avoid delaying your condition.
Complication
Dysphagia complications Complications, cardia cancer, esophageal cancer, reflux esophagitis
It can lead to nutritional disorders, nutritional disorders, can be caused by insufficient or excessive proportion of one or more nutrients, and can also have too much or insufficient energy. Dietary loss of appetite, weight loss, and even nausea, sleep disorders, etc. are often indicative of the possibility of a nutritional disorder. As well as the possibility of complications caused by the primary disease of dysphagia, it is necessary to carry out specific analysis in combination with the primary disease.
Symptom
Symptoms of dysphagia Common symptoms Dysphagia Dysphagia, swallowing, sputum, food, swallowing, neck, swallowing, small fingernails, depression
History
(1) Age and gender: Children with dysphagia, often caused by congenital esophageal disease or esophageal foreign body; middle-aged patients with dysphagia symptoms gradually aggravated, should first consider esophageal cancer, more common in men; iron deficiency dysphagia The majority of patients are women, often with other clinical symptoms of iron deficiency anemia.
(2) medical history and incentives: esophagus with history of corrosive damage should consider esophagitis, benign stenosis; frequent reflux of gastric acid or bile is mostly reflux esophagitis (acidic or alkaline reflux); high incidence of esophageal cancer Patients should first consider esophageal cancer; dysphagia is caused by emotional agitation, suggesting that it may be caused by esophageal achalasia, primary esophageal fistula or neurosis (coloation).
(3) Obstruction site: The obstruction site shown by the patient is generally consistent with the anatomical site of the esophageal lesion. It has the reference significance of localization diagnosis. In addition to the cancer of the upper esophagus, in addition to cancer, it can be swollen thyroid, tuberculous or malignant granuloma. , iron-deficiency anemia of the pharynx, cervical esophageal fistula (congenital abnormalities) and other diseases; middle obstruction is often esophageal cancer, mediastinal lesions compression esophagus, esophageal benign stenosis, esophageal polyps, esophageal submucosal tumors, etc. Caused by the disease; dysphagia in the lower esophagus is mainly caused by diseases such as cancer and esophageal achalasia.
(4) Relationship with eating: mechanical dysphagia may cause obstructive symptoms in solid food, soft food, and fluid in turn as the degree of obstruction of the lumen is increased; exercise dysphagia such as esophageal achalasia, esophageal fistula patients eat solid Or dysphagia in flu swallowing; if the cerebral neuropathy causes swallowing muscle paralysis, the uncoordinated movement can be expressed as drinking water rumbling (water sputum into the trachea).
(5) Accompanying symptoms:
1 dysphagia with hiccups often suggest lower esophageal lesions such as cardia cancer, achalasia, sputum and so on.
2 with hematemesis seen in esophageal cancer, granulomatous lesions, reflux esophagitis or ulcers.
3 with swallowing pain more common in oropharyngeal inflammation or ulcers, esophageal inflammation or ulcers, esophageal achalasia and so on.
4 with unilateral wheezing often suggest that mediastinal tumor compression of the esophagus or compression of the main bronchus may be.
2. Signs
Physical examination should pay attention to the patient's nutritional status, with or without anemia, superficial lymphadenopathy, goiter, neck mass, abnormal swallowing muscle activity, etc., if necessary, for neurological examination to identify the cranial nerves associated with swallowing (IX , X, XII on the cranial nerve), whether there is abnormality in the swallowing muscle.
3. Laboratory and other auxiliary inspections
Examine
Dysphagia check
Drinking water test
The patient takes a sitting position and places the stethoscope between the patient's xiphoid process and the left rib arch. Drinking a sip of water, a normal person can hear a jet murmur after 8 to 10 s. If there is an esophageal obstruction or movement disorder, no sound is heard or Delayed appearance, severe obstruction can even vomit water, this method is simple and easy, can be used as a method to initially identify the presence or absence of obstruction of the esophagus.
2. Esophageal acid test
It is important for the diagnosis of esophagitis or esophageal ulcer. The patient takes a sitting position and is introduced into the nasogastric tube and fixed at 30cm from the outer nostril. The saline is first instilled, 10~12ml per minute. After 15min, the infusion of 0.1N at the same speed is carried out. Patients with hydrochloric acid, esophagitis or ulcers usually have post-sternal burning pain or discomfort within 15 minutes, and then switch to saline infusion to gradually relieve the pain.
3. Esophageal 24-hour pH monitoring
24-hour pH monitoring in the esophageal lumen is important for diagnosing acidic or alkaline reflux.
4. Conduct an examination of immunology and tumor markers.
Auxiliary inspection
X-ray inspection
X-ray chest radiograph can understand whether there is any foreign body in the mediastinum or esophagus with or without space-occupying lesions; esophageal X-ray barium meal examination can observe the presence or absence of expectorant retention, to judge the lesion as obstructive or muscle peristalsis, if necessary The changes of esophageal mucosal folds were studied by gas sputum double contrast.
2. Endoscopy and biopsy
Esophageal lesions can be directly observed, such as esophageal mucosal congestion, edema, erosion, ulcers or polyps, cancer, etc.; can observe the presence or absence of stenosis or local expansion of the esophagus, with or without achalasia, biopsy biopsy, right Identification of esophageal ulcers, benign tumors and esophageal cancer are important.
3. Esophageal manometry
Esophageal manometry can be used to determine the functional state of esophageal movement. Generally, the lateral pressure of the lower esophageal sphincter (LES) is 12-20 mmHg, the pressure of LES/intragastric pressure is >1.0, and the pressure is 10 mmHg. Pressure / intragastric pressure <0.8, suggesting gastroesophageal reflux, but people found that gastroesophageal reflux and normal people LES pressure overlap, and later changed to catheter extraction method to measure pressure, take the end of expiratory LES pressure Quasi-measures of patients with esophageal achalasia can only see non-creeping small contraction waves, and there is no obvious peristaltic contraction wave after swallowing action; while patients with esophageal fistula can detect strong esophageal contraction wave, LES relaxation function is good.
Diagnosis
Diagnostic diagnosis of dysphagia
Diagnosis is based on clinical performance and examination.
Differential diagnosis
Esophageal cancer
Esophageal cancer is more common in male patients over 40 years old. The typical symptoms are progressive dysphagia. Most patients can clearly indicate that the obstruction site is behind the sternum and may be accompanied by swallowing pain. Late patients may have esophageal reflux, often mucinous or Mixed food or food every other day, when the food can not pass through the cardia, the vomit is not acidic; X-ray swallowing can be seen in the esophageal local mucosa thickening or interruption, irregular stenosis, sometimes see a small shadow; esophageal exfoliative cytology It is important for early diagnosis. Esophagoscopy or endoscopy combined with biopsy can determine the diagnosis of esophageal cancer.
2. Esophageal achalasia
Because the esophageal peristaltic wave is weakened or disappeared, the LES loses flaccid, so that the food can not pass through the cardia frequently. The dysphagia is often intermittent, and the course of disease is longer. The lower part of the esophagus (ie, above the stenosis) is obviously dilated, the esophageal reflux is common, and the counterflow is relatively large. , without bloody mucus, especially in the supine at night can be awakened by cough, and even lead to aspiration pneumonia, patients often have no significant progressive weight loss symptoms, X-ray swallowing examination shows that the cardia obstruction is fusiform or funnel-shaped, smooth edges After inhalation of isoamyl nitrite, the cardia can be temporarily relieved, and the expectorant can be passed; the esophageal manometry can only see non-creeping small contraction wave; the esophagoscopy or gastroscope sees the lower part of the esophagus mucosa is normal, there is no new organism in the esophageal cavity, sometimes The endoscope cannot pass through the stenosis, and the mucosa biopsy has no cancer cells.
3. Gastric-esophageal reflux disease
Due to dysfunction of the lower esophageal sphincter, the anti-gastroesophageal reflux barrier function is lost, and the stomach and duodenal contents often flow back into the esophagus, eventually leading to chronic inflammation of the esophageal mucosa, and even ulceration, mainly as a post-sternal burning sensation or Pain, accompanied by dysphagia, mostly caused by acid, supercooled, overheated food-induced esophageal fistula, often accompanied by benign esophageal stricture in the later stage, LES pressure measurement in the lower esophagus, 24-hour pH monitoring in the esophagus, Bilitee-2000 bile monitor The bilirubin absorption value is helpful for the diagnosis of acid and alkali reflux. The lesions are obvious. In esophagoscopy or gastroscopy, the mucosa is inflammation, erosion or ulceration, early reflux or mild lesions, erosion or ulceration. Not obvious.
4. Benign stricture of the esophagus
The stenosis is caused by corrosive factors, esophageal surgery, injury, reflux esophagitis, dysphagia due to scar stenosis, long course of disease, progressive aggravation, often accompanied by anti-feeding, X-ray swallowing examination can be seen in the lumen Narrow, but the edges are neat, no signs of shadowing, and esophagoscopy or gastroscopy can confirm the diagnosis.
5. Diffuse esophageal fistula
More secondary to reflux esophagitis, corrosive esophagitis and other diseases, often confused with angina pectoris, and the cause of primary diffuse esophageal fistula is unknown, can be seen at any age without esophagitis, the main symptom is swallowing Difficulties and swallowing pain are mostly caused by mental factors such as emotional agitation. The swallowing pain can be located in the front chest and even radiated to the forearm. The nitroglycerin can also relieve pain.
6. Other
Esophageal fistula, mediastinal tumor, enlarged lymph nodes around the esophagus, obvious enlargement of the left atrium, aortic aneurysm, etc., such as compression of the esophagus can cause difficulty in swallowing, but according to symptoms, signs, X-ray, CT, MRI, etc. Auxiliary examinations can be diagnosed separately. These lesions can be seen in the esophageal cavity when the esophageal swallowing examination changes.
