spontaneous esophageal rupture
Introduction
Introduction to spontaneous esophageal rupture Spontaneous Rupture of Esophagus refers to a sudden increase in pressure in the esophageal lumen caused by various reasons, resulting in a longitudinal tear of the entire left side wall of the esophagus on the adjacent diaphragm. Also known as Boerhaave syndrome, spontaneous esophageal tear syndrome, esophageal pressure rupture, esophageal digestive perforation, non-traumatic esophageal perforation, etc., most occur after drinking, vomiting. basic knowledge The proportion of sickness: 0.007% Susceptible people: men aged 40-60 Mode of infection: non-infectious Complications: shock, mediastinal emphysema, pneumothorax, pleurisy
Cause
Spontaneous esophageal rupture
Stress factor (30%):
The stress factor causing spontaneous esophageal rupture is not the absolute pressure in the stomach, but the pressure difference of the transesophageal junction. After the perforation of the esophagus, if there is no communication with the pleural cavity (the mediastinal pleura is not broken), the strong acidic gastric juice, stomach content The object and the swallowed oral saliva containing a large amount of bacteria, under the action of the negative pressure of the pleural cavity, overflow into the mediastinum through the perforation, mainly causing the infection of the mediastinum infection and digestive juice, but in the later stage, the infected substance can also penetrate the mediastinum. The pleura enters the pleural cavity, causing a chest infection. If the mediastinal pleura is ruptured at the same time after perforation of the esophagus, the chest infection is the main manifestation.
Vomiting (40%):
Although not 100% of patients have vomiting at the time of onset, most patients (70% to 80%) have vomiting followed by esophageal perforation, so vomiting is still the most important cause of illness, and smoking is associated with vomiting. Most of the patients who vomit are overeating, and vomiting occurs after drinking.
Other (9%):
Other causes of spontaneous esophageal rupture include childbirth, car accident, post-cranial surgery, epilepsy, etc. Spontaneous esophageal rupture is caused by increased abdominal pressure conduction to the esophagus, which can be formed at the distal end of the esophagus, and the cleft is more common in the lower esophagus. Because the upper segment is mainly skeletal muscle, it is not easy to rupture, while the middle and lower segments are mainly smooth muscle. The longitudinal muscle fibers are gradually reduced, the muscle layer is thin, the vascular nerve is less, and it is easy to rupture. The crack is mostly vertical, 4 to 7 cm long, in the lower pulmonary vein. Near the level.
Pathogenesis:
Under normal circumstances, when vomiting occurs, the intragastric pressure suddenly increases, the esophagus is reflexively relaxed to discharge the stomach contents, if the vomiting action occurs ataxia, the esophageal sphincter can not relax or a certain contraction of the esophagus, then the stomach The contents can not be discharged, the pressure in the esophagus increases sharply, leading to the full-layer rupture of the esophageal wall with weak local resistance. Adult spontaneous esophageal injury does not occur frequently. Once it occurs, the esophagus of the thoracic and abdominal segments is involved, and the esophagus of the cervical segment occurs. Spontaneous perforation is rare, and spontaneous esophageal injury is divided into three categories: 1 interstitial hematoma (incomplete perforation); 2 mucosal tear (Mallory Weiss syndrome); 3 complete rupture (Boerhaave syndrome), in adults Increased intra-abdominal or esophageal pressure can cause esophageal injury. Elevation of esophagus, severe vomiting, esophageal fistula or foreign body, including food mass obstruction of the esophagus, causing a sudden increase in esophageal pressure, such as weight lifting, fecal exertion or abdominal ablation. Perforation can occur.
Neonatal can also have spontaneous esophageal rupture, which is rare. Acute dyspnea within 48 hours after birth should exclude spontaneous esophageal rupture of the esophagus. Esophageal rupture often involves the full esophagus. Most cases extend to the right thoracic cavity. The exact mechanism is unknown. It may be that the upper end of the esophagus is obstructed, causing the pressure in the esophagus to increase. The pressure during delivery is transmitted to the esophagus filled with amniotic fluid. When the glottis and the pharynx are closed, the pressure in the esophageal lumen is increased. When the pharyngeal muscles and the upper esophageal muscle layer are uncoordinated or the esophageal hypertension may occur after birth, the esophageal perforation may occur.
Prevention
Spontaneous esophageal rupture prevention
Spontaneous rupture of the esophagus occurs almost in the case of a sudden increase in intra-abdominal pressure. The rate of increase in pressure is more important than the absolute value of the increase in pressure. The sudden increase in intra-abdominal pressure is more common in a stomach full of food after a meal. Danger, this is because the stomach of the food is more unable to withstand the increase of pressure, the most common cause is vomiting (70% to 80%), when the vomiting occurs, the stomach pyloric contraction can not push the stomach contents downwards. At the same time, the rapid contraction of the diaphragm and abdominal muscles causes the intra-abdominal pressure to rise rapidly. Therefore, preventing the sudden increase of the intra-abdominal pressure is the key to prevention.
The prognosis of this disease depends on the time of diagnosis, the location of the rupture, the underlying disease, the esophageal basis, and the presence or absence of spontaneous parietal pleural rupture, although the mortality of Boerhaaves syndrome has been greatly reduced since Barrett first successfully sutured the gap in 1947 (31). %), but delayed diagnosis can significantly increase complications, increase the difficulty and cost of treatment, and is the main cause of high mortality. Clinicians must be highly vigilant about this disease, comprehensive observation, thinking, early diagnosis, correct treatment, can save More patients.
Complication
Spontaneous esophageal rupture complications Complications, shock mediastinal emphysema, pneumothorax pleurisy
If left untreated, the patient may die from severe necrotizing mediastinal inflammation and endotoxin shock, with a mortality rate of 30% to 70%.
1. Shock: Due to severe pain, hypoxia and blood loss, the patient often falls into a state of shock, which is characterized by restlessness, paleness, rapid pulse, and decreased blood pressure. If not rescued in time, the patient can die in a short time.
2. Mediastinal inflammation and mediastinal emphysema : After esophageal rupture, esophageal and gastric contents can enter the mediastinum through the esophageal sulcus to cause mediastinal inflammation, which is characterized by high fever, pulse frequency, and increased white blood cells.
3. After the rupture of the liquid gas chest tube, there is a mediastinal pleural puncturing. The gas and esophageal contents quickly enter the chest cavity, causing pneumothorax, liquid pneumothorax, empyema, pus and pneumothorax, and corresponding symptoms and signs appear.
4. The formation of esophageal rupture caused by mediastinal inflammation and pleurisy, and then into a chronic stage, esophageal and pleural perforation surrounded by connective tissue to form esophageal pleural fistula or esophageal mediastinum, patients with chronic inflammation, esophageal iodine angiography can confirm The presence of a fistula.
Symptom
Spontaneous esophageal rupture symptoms Common symptoms Nausea low fever black stool bowel peritonitis satiety chest pain acute abdomen abdominal pain hypotension shock
symptom
(1) The initial symptoms are vomiting, nausea, upper abdominal pain, chest pain, 1/3 to 1/2 patients have hematemesis, vomiting patients often have a history of drinking or overeating, the pain is mostly in the upper abdomen, but also in After the sternum, the two seasons of the ribs, the lower chest, sometimes radiated to the shoulders and back, when the symptoms are severe, there may be shortness of breath, difficulty breathing, cyanosis, shock and so on.
(2) physical examination is often manifested as acute abdomen, may have the corresponding signs of liquid pneumothorax, upper abdominal tenderness, muscle tension, and even plate, esophagus, stomach contents into the chest, peritoneal cavity can cause chemical chest, peritonitis, can There are acute suppurative mediastinal inflammation and chest and peritonitis.
classification
The main clinical manifestations of spontaneous esophageal rupture are chest pain and upper gastrointestinal bleeding. The different types of manifestations are as follows:
1. Perforation of esophageal wall: clinically more common in elderly women, often followed by severe pain in the posterior sternal and posterior sternal and upper abdomen, and quickly radiated to the back, with a small amount of hematemesis and hypothermia, no mediastinal emphysema and subcutaneous emphysema .
2.MalloryWeiss syndrome: adult males aged 40 to 60 years old, most patients have binge drinking or long-term drinking habits, but also due to regular aspirin, the patient complained of hematemesis after a large amount of vomiting and retching, Often contain blood, there are also cases of black stools, only a small number of patients with chest pain.
3. Boerhaaave syndrome: It is also more common in middle-aged men. The typical medical history is severe nausea and vomiting after a large amount of diet. There are severe lower chest and xiphoid pain in the lower esophageal perforation. There may be radiation pain in the back and shoulders. Some patients Only upper abdominal pain, accompanied by shortness of breath, difficulty breathing or shock, etc., may occur hypotension, heart rate and respiratory rate increased, gas through the esophageal rupture of the mouth to form mediastinal emphysema, and then hemorrhage on the sternum and chest wall subcutaneous emphysema, auscultation Can be heard pleural or pleural pericardial rub sound, is a sign of pleural effusion or liquid pneumothorax, there are signs of upper abdominal tenderness, bowel sounds reduced or disappeared.
Examine
Spontaneous esophageal rupture
Patients with esophageal rupture can have no fever in the early stage, and white blood cells do not rise; later, there may be fever, chills, and white blood cells.
1. Thoracentesis : After the liquid pneumothorax, the diagnostic puncture is simple and necessary. If the extract is a bloody sour liquid, or the food dregs are found, the diagnosis can be confirmed. After the oral methylene blue, the thoracic puncture is performed, such as taking out the blue. The diagnosis of this disease can be confirmed by pleural effusion or by injecting methylene blue into the thoracic cavity and then withdrawing blue fluid from the esophagus.
2. Increased amylase in pleural effusion .
X-ray examination found mediastinal emphysema, left pneumothorax, pleural effusion, liquid pneumothorax may be diagnosed, in the chest radiograph can not be diagnosed with or without perforation, can be swallowed a small amount of water-soluble contrast agent, if found to have contrast agent Spillage can be diagnosed and positioned immediately.
3. X- ray examination : the first choice, the perforation of the esophageal wall and the interstitial hematoma when X-ray barium meal examination showed a persistent sputum residual area on the esophageal wall to the occupying filling defect, and the hematoma communicating with the lumen appeared. Double esophageal signs, two masts can be quickly emptied, there is a translucent band representing the mucosal flap, Boerhaave syndrome X-ray film sees varying degrees of mediastinal emphysema, pleural effusion and liquid pneumothorax, left rim due to chemistry Pneumonia can be seen in flaky irregular shadows, Naclerio called the "V" sign, oral water-soluble contrast agent diatrizoate or tincture, which helps to locate, especially in clinically unclear, but for the MalloryWeiss syndrome chest X-ray photographs and esophagography have no more positive findings. X-ray chest fluoroscopy is of great value. Many patients have found a liquid pneumothorax through emergency chest fluoroscopy, and noticed that mediastinal emphysema can be seen on the lateral side of the chest radiograph. The subcutaneous emphysema of the neck, the posterior anterior position can sometimes be seen on the posterior mediastinal side of the emphysema shadow, a triangle, taking into account the esophageal rupture, should be taken iodine oil film, clear diagnosis.
4. Esophagoscopy : can be found in the esophageal rupture site, the diagnosis, positioning, treatment uniform meaning.
Diagnosis
Diagnosis of spontaneous esophageal rupture
According to the medical history, clinical manifestations and laboratory data is not difficult to make a diagnosis.
Differential diagnosis
Because the disease is rare in clinical practice, it is often missed and misdiagnosed. This disease is often similar to other common heart and upper gastrointestinal diseases. The rate of misdiagnosis is as high as 37.5% to 84%. The most common confusion is peptic ulcer perforation ( 41% of patients with peptic ulcer or myocardial infarction, such as esophageal rupture into the pericardium, is more difficult to distinguish from myocardial infarction. When suspicious cases are found, attention should be paid to the following diseases:
1. Perforation of ulcer disease: patients often have a history of ulcers, sudden onset, with severe upper abdominal pain as the main performance, abdominal examination showed abdominal muscle tension, tenderness and rebound tenderness, abdominal X-ray examination showed free gas under the armpit.
2. Spontaneous pneumothorax: often has a history of chronic obstructive pulmonary disease, sudden severe chest pain and difficulty breathing. The typical X-ray signs are compression of the lung tissue to the hilar part. Gas often accumulates in the outside of the thoracic cavity or the tip of the lung. Increased, the lung texture disappears.
3. Angina pectoris, myocardial infarction often has high blood pressure, history of diabetes, older, mostly due to fatigue, eating, stimulating and induced, chest pain has its characteristics, including nitroglycerin can relieve symptoms.
4. The clinical manifestations of acute pulmonary embolism can range from asymptomatic to sudden death. Common symptoms are dyspnea and chest pain, hemoptysis, rapid breathing, cyanosis, frequent wet or wheezing in the lungs, pulmonary vascular murmur, pleura. Scrubbing sound or pleural effusion, the circulatory system may have the corresponding manifestations of acute pulmonary heart disease, X-ray shows patchy infiltration, atelectasis, diaphragmatic elevation, pleural effusion, especially with the pleura as the base convex surface toward the hilum Circular dense shadows, and dilated pulmonary arteries with sparse lung texture are of diagnostic value for pulmonary embolism. Radionuclide ventilation/perfusion scan is the most sensitive non-invasive method for the diagnosis of this disease.
5. Dissection aneurysm: acute chest pain, increased blood pressure, sudden aortic regurgitation, pulse on both sides, or pulsatile mass should also consider the disease, echocardiography, CT, MRI, DSA, etc. The examination can confirm the diagnosis.
6. Acute pancreatitis: This disease often has a history of overeating, drinking, gallstones, etc., with severe upper abdominal pain as the main manifestation. B-ultrasound and other imaging examinations can show diffuse or localized enlargement of the pancreas, blood, urine. The amylase is elevated and the blood lipase is elevated.
7. Incarcerated : refers to the pathological state of the intra-abdominal or retroperitoneal organs entering the chest through the diaphragmatic fissure or defect. When the organ is incarcerated, nausea, vomiting, chest tightness, shortness of breath, cyanosis, tachycardia, etc. may occur. Symptoms, severe cases can produce dyspnea, circulatory failure, percussion of the chest side of the drum, can be heard and bowel sounds, chest X-ray examination showed that the contour of one side of the face is unclear, in the chest cavity can be seen in the intestines inflated or stomach bubble The irregular transparent area, often accompanied by the liquid level, can be clearly diagnosed by gastrointestinal barium meal examination or artificial pneumoperitoneum.
8. The clinical manifestations of mesenteric artery embolization showed severe abdominal pain in the early stage, but the signs were often not obvious, mostly accompanied by nausea, vomiting, blood or melena, and even intestinal obstruction. The patient was older and often had heart disease or infective heart. Membrane inflammation, arteriosclerosis, history of coronary heart disease, mesenteric angiography can confirm the disease.
