Esophageal perforation
Introduction
Introduction to esophageal perforation Perforation of esophageal perforation (esophagus) is one of the most serious gastrointestinal emergency cases, and its mortality rate is reported to be 10% to 46%. The prognosis depends on the cause of the disease, the site of the injury, the underlying lesion of the esophagus, and the time at which the treatment begins after the injury. Early diagnosis and treatment depend on a high degree of vigilance against the disease and a correct judgment of the corresponding clinical manifestations. basic knowledge The proportion of illness: 0.003% Susceptible people: no special people Mode of infection: non-infectious Complications: Pneumothorax Shock
Cause
Esophageal perforation
(1) Causes of the disease
Cause
Alcoholism, severe vomiting in pregnancy, severe seasickness, overeating, weight gain, long-term cough or hiccup, persistent state of asthma, infant and seizures, distal obstruction of the esophagus (eg, tumor, stenosis, esophageal ring, esophageal reticular septum) ), swallowing can also lead to pressure rupture of the esophagus, neurological disorders (such as brain tumors, cerebral hemorrhage, cerebral aneurysms and craniotomy) can increase the incidence of pressure esophageal rupture by 10 times.
2. Classification and characteristics
According to the reasons, esophageal perforation can be divided into traumatic esophageal perforation, eruption of esophagus caused by shock wave, iatrogenic esophageal perforation, perforation caused by foreign body of esophagus and spontaneous esophageal rupture.
(1) Traumatic esophageal perforation: Traumatic esophageal perforation is divided into open esophageal perforation and closed esophageal perforation. The open esophageal perforation is mainly caused by bullets, shrapnel and blade, and the esophagus has its anatomical position. In particular, the thoracic esophagus, the posterior spine, the heart, the large blood vessels, the trachea and the sternum, and the lungs and ribs on both sides, so the thoracic open esophageal perforation is very rare, even if the esophagus is damaged, often combined with the heart, large In the injury of blood vessels and trachea, the patient was too late to rescue and sacrificed to the scene. Llic et al reported that among the 2494 wounded in the Bosnian War in 1991-1995, only 5 cases had esophageal injuries, accounting for 0.2%. In the domestic acrobatic performance, swallowing swords caused by esophageal perforation. Reported, therefore, open esophageal perforation in the open esophageal injury is more common, closed esophageal perforation can cause extensive rupture of the esophagus due to sudden compression between the sternum and the spine, such damage is even more rare, there have been motorcycle impact Report of bronchial esophageal fistula causing esophageal rupture.
(2) Eruption of the esophagus caused by shock wave: The high-pressure shock wave is transmitted into the esophagus through the oral cavity, causing the pressure in the esophageal cavity to rise sharply and causing the esophagus to rupture. There have been many cases of tire burst in the country, and the impact of the gas cylinder wave shock causing the esophagus to rupture, shock wave The mechanism that causes esophageal rupture is mainly the direct effect of overpressure and negative pressure. The high pressure shock wave can be forced into the esophagus through the nostrils. Since the cardia is usually in a contracted state, high pressure is generated in the esophagus like a blind tube, and the airflow is on the chest. Abdominal and other body functions are weak, abdominal wall, thoracic, diaphragm, glottis and other non-reflective protective actions, the chest cavity is still negative pressure, so the pressure difference inside and outside the esophagus can cause esophageal rupture.
(3) iatrogenic esophageal perforation: the most common cause of iatrogenic esophageal perforation is perforation caused by endoscopy, esophageal dilation, esophagoscopy, and esophageal surgery. Pogodina reports 850 cases of penetrating esophageal injury. 368 cases (43.3%) were caused by instruments, which accounted for the first place in esophageal perforation for various reasons. Avanoglu (1998) reported that in 12,249 cases of esophageal dilatation after esophageal burn, 52 cases were perforated, accounting for 4.16%. , tracheal intubation, insertion of gastric tube, three-lumen tube rupture, and even esophageal dynamics have reports of esophageal perforation, tracheal incision and damage to the esophagus is rare, but should still cause the attention of the operator, from the esophagus Most of the perforations caused by endoscopy occur in the lower part of the esophagus at the entrance of the pharyngeal muscle. Here, there is a ring-shaped cartilage, a cervical vertebra, and a pharyngeal muscle around it. It is the narrowest part of the esophagus. The lower part of the esophagus and the pericardium are perforated. It is based on the original disease of the esophagus. Berry reported that the basic lesions associated with perforation of the esophagus were the most common with hiatal hernia, followed by stenosis, achalasia, sputum and tumor.
The mortality of iatrogenic perforation is lower than that caused by other causes. The reason may be: 1 about 40% of perforation is seen in the cervical esophagus, and the perforation of the cervical segment is better than that of the intrathoracic perforation; Early detection, timely treatment; 3 preparations for fasting before the examination, pollution reduction; 4 examination caused by the esophageal perforation is mostly small, causing mediastinal and chest infections are also lighter.
Mediastinal surgery, hiatal hernia repair and vagus nerve cutting may cause perforation of the esophagus, which is common in the lower esophagus or intra-abdominal esophagus, and mostly in the posterior wall of the esophagus. It is more likely to cause esophagus when there is adhesion around the esophagus for blind separation. damage.
(4) Foreign body esophageal perforation: foreign body incarceration is also a common cause of esophageal perforation. Among 850 cases of esophageal perforation reported by Pagodina et al, 328 cases were caused by foreign bodies, accounting for 38.6%, ranking second only to perforation caused by instruments. 2, causing perforation of the esophagus is sharp, non-plastic or bulky foreign objects, such as bones, dentures, etc., currently electric toys are popular in developed countries, children can swallow the esophagus to cause esophageal perforation, especially Lithium batteries are more corrosive, and are more likely to cause perforation of the esophagus, foreign matter puncture or compression of the esophageal wall to cause necrosis, or forcibly swallowing rice balls or large pieces of food to try to push the foreign body down and cause perforation of the esophagus. Excision of foreign bodies caused by irregularities causes perforation of the esophagus. The perforation of the esophagus caused by foreign bodies is common in the three physiological stenosis areas of the esophagus. The perforation of the aortic arch is particularly serious, and there is a risk of spurting and corroding the aorta causing fatal bleeding. If it is difficult to remove the foreign body through the endoscope, it is relatively simple and safe to open the chest with an emergency and cut the foreign body before the infection occurs.
(5) Spontaneous esophageal rupture (Boerhave syndrome): spontaneous esophageal rupture is rare. In 1724, Boerhave first reported a case of esophageal rupture caused by eclipse after overeating, which is also known as Boerhave syndrome, although its incidence Only 1/6000, accounting for 15% of all esophageal perforations, but the mortality rate is as high as 25% to 100%. The cause of this type of patients is relatively clear, most of them occur after binge eating and heavy drinking. In this case, vomiting makes the abdomen The internal pressure suddenly rises, the pressure on the stomach makes the pressure in the esophageal cavity suddenly increase, and the reflex phlegm of the pharyngeal muscle is contracted. The esophagus is in the negative thoracic cavity. At this time, the pressure in the esophageal cavity and the thoracic cavity is instantaneous. The difference is very large, which leads to the rupture of the whole esophagus. As for the pressure required to cause the esophageal rupture, there is no reliable data. The pressure on the cadaver to cause the esophageal rupture is about 0.90~2.72kg/6.451cm2, except for the cause of vomiting. There are also reports of childbirth, convulsions, forced bowel movements, etc., spontaneous esophageal rupture is more common in the lower esophagus, the reason is that the upper esophageal wall is mainly striated muscle, response to stimuli, The corresponding contraction is not easy to rupture, and the lower part of the esophagus is mainly smooth muscle, which is slow to stimulate and easy to rupture. The muscle layer of the middle esophagus has both striated muscle and smooth muscle. The rupture may be between the two, and the esophagus spontaneously ruptures. The cracks are mostly longitudinal single slits, ranging from 2 to 9 cm in length, but there are also reports of two ruptures, which should be investigated during surgery.
Vomiting, chest pain, subcutaneous emphysema is a typical clinical manifestation of spontaneous esophageal rupture. Due to lack of awareness and vigilance of the doctor, it is often misdiagnosed as gastric or duodenal perforation, liquid pneumothorax, acute pancreatitis, myocardial infarction, acute appendicitis. Etc. Even if you have misdiagnosed acute abdomen and laparotomy, the rate of misdiagnosis can be as high as 75%. Delayed diagnosis and treatment is an important cause of death. 121 cases of spontaneous esophageal rupture with death record in the third national conference on benign esophageal diseases. Among them, the mortality rate is as high as 37.2%.
(two) pathogenesis
Although the causes of perforation of the esophagus are different, the pathophysiological changes after perforation are consistent. After the perforation of the esophagus, the gastric contents with strong stimulating effects and the saliva and food with various oral bacteria are quickly broken. Entering the mediastinum, causing severe mediastinal infection, inflammation rapidly spreads in the mediastinum, and can erode through the pleura into the chest cavity, forming one or both sides of the liquid pneumothorax, because the bacteria entering the anaerobic bacteria often cause rancid empyema. At the same time, when the esophagus ruptures, the pleura is ruptured, the liquid pneumothorax appears very early, the mediastinum and thoracic cavity infection, the loss of a large amount of fluid, the absorption of toxins, the patient can quickly experience shock, and the air is continuously rushed into the chest cavity due to swallowing. It can produce tension pneumothorax, more severe breathing and circulatory dysfunction. If not treated in time, the patient can die quickly.
The reason for the rapid spread of inflammation in the mediastinum is:
1. The mediastinum is loose connective tissue. Except for the narrow entrance of the thoracic cavity, there is no other organ tissue enough to block the spread of infection. After perforation of the esophagus, the air enters the mediastinum to form mediastinal emphysema. The digestive juice enters the mediastinum and creates favorable conditions.
2. During the inhalation process, the mediastinal negative pressure increases, which is more conducive to the inhalation of air and digestive juice into the mediastinum.
3. The beating of the heart, the peristalsis of the esophagus and the swallowing activities all contribute to the spread of infection.
4. The mouth contains a variety of bacteria, such as spirochetes, microaerobic bacteria, non-hemolytic streptococcus and some other bacteria, especially when the mouth is infected, it plays an important role in the spread of mediastinal infection and inflammation.
Prevention
Esophageal perforation 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.
Complication
Esophageal perforation complications Complications
1. Difficulty breathing:
When the thoracic esophagus is perforated, the patient may have severe breathing difficulties and cyanosis due to the liquid pneumothorax on one or both sides.
2. Shock:
Due to the loss of body fluids, the absorption of toxins can cause shock in severe cases.
Symptom
Esophageal perforation symptoms Common symptoms pronunciation shortness of breath, difficulty breathing, swallowing difficulty, back pain, chest pain, food, misunderstanding, airway tension, shaking water, abdominal pain
The clinical manifestations of esophageal perforation are related to the location and time of injury.
1. Symptoms and signs
(1) cervical esophageal perforation: pain in the patient's neck, neck pain and often accompanied by tenderness of the sternocleidomastoid muscle, sputum, can still have difficulty in pronunciation, difficulty swallowing and hoarseness, 60% of patients have a neck during physical examination Subcutaneous emphysema, and X-ray examination can confirm the diagnosis of 95% of patients.
(2) Thoracic esophageal perforation: the patient feels the chest area, the interscapular region and the pain under the xiphoid. The pain can be aggravated during swallowing and deep breathing. The characteristics of back pain caused by extensive inflammation of the posterior mediastinum and the thoracic aortic dissection aneurysm The pain is very similar. Chest esophageal perforation often has muscle tension in the upper abdomen, difficulty in swallowing, pain during swallowing, difficulty in breathing, hematemesis, cyanosis, chest auscultation and snoring of mediastinal emphysema, ie Hamman sign, as inflammation progresses There may be tachycardia, shortness of breath and fever. If not treated in time, sepsis and shock may occur further.
(3) abdominal perforation of the esophagus: mainly manifested as pain under the xiphoid, muscle tension, paralysis and rebound tenderness, once tachycardia, shortness of breath and fever, etc., can quickly develop into sepsis and shock is abdominal perforation specialty.
Esophageal pericardial stenosis can occur when the perforation affects the posterior pericardium. These patients may have cardiac tamponade or systolic tremors of the heart during the visit. The perforation of the esophagus invades the heart chamber (usually the left atrium), which can cause whole body food granule embolism. But this is rare in esophageal perforation.
2. Staging
According to the occurrence process of esophageal perforation, it is divided into acute, subacute and chronic.
(1) Acute esophageal perforation: Acute postoperative perforation occurred within 24 hours of acute esophageal perforation. Acute perforation is more common in instruments or spontaneous perforation. Clinically, chest pain or abdominal pain, difficulty in breathing, fever and skin burst are the main symptoms.
(2) Subacute perforation: subacute perforation occurred within 24h to 2 weeks after injury, and the clinical manifestations were chest pain and dyspnea.
(3) Chronic perforation: chronic perforation occurs at the top of the injury 2 weeks after the injury, and chronic perforation occurs after surgery. The patient may have difficulty swallowing and atrial arrhythmia. The clinical characteristics of chronic perforation reflect the limitation after perforation. The degree, but does not reflect the degree of urgency of perforation itself. Chronic perforation is mostly limited and rarely causes extensive mediastinal contamination, and its clinical course is also moderate.
Examine
Esophageal perforation
1. Determination of pleural pH
The pH of the normal human pleural fluid is about 7.4. If the extracted thoracic fluid is acidic and the pH is less than 6, the lower esophageal rupture should be considered.
2. Blood routine
As the inflammation progresses, leukocytosis can occur.
3. Bacterial culture
Take the esophageal secretions or puncture fluid for bacterial culture and drug sensitivity test.
4. Oral methylene blue solution
The thoracic fluid is blue and can be used as a strong evidence of esophageal perforation.
5. Esophagoscopy
Esophagoscopy should be performed when the esophageal rupture is suspected and the X-ray is negative.
6. X-ray film
Mediastinal emphysema can be found in X-ray examination in 40% of patients.
(1) Neck esophageal perforation: There is free gas in the cervical fascia layer, suggesting local swelling and subcutaneous emphysema.
The contrast agent leaked out of the esophagus.
(2) Chest esophageal perforation: X-ray image shows mediastinal or mediastinal widening, one or both sides of the liquid pneumothorax, if there is a mediastinal abscess formation, can show dense shadow, gas-liquid surface, lipiodol or water-soluble iodine Esophageal angiography, visible contrast agent spillover.
7.CT scan
From neck scan to pubic symphysis, CT images showed thickening of the esophageal wall, accumulation of fluid around the esophagus, accumulation of gas outside the esophagus, and pleural effusion. The gas outside the esophagus is the most valuable sign, and some patients can be found. Rupture holes, for patients with atypical clinical symptoms, CT can clearly show that extraluminal changes are helpful for diagnosis.
In addition, CT can also find subcutaneous emphysema in the mediastinum, neck, chest and upper abdomen, widening of mediastinum, effusion around the esophagus and mediastinum, abscess, swelling of soft tissue in the mediastinum, trachea, bronchi, blurred blood vessels, local effusion, etc. Local abscess showed central water sample density, high peripheral density, enhanced edge after angiography, mediastinal inflammation and granuloma can cause mediastinal tissue and organ displacement, CT scan can clearly show pneumothorax, pneumonia, atelectasis, bronchial rupture, pericardial complication Fluid, aortic rupture and fractures, thin-layer scan can be found in the perforated esophageal defect, and when the sputum is cyanosis, CT scan can be seen that the diaphragmatic rupture is absent. Because of the different tissues, the CT manifestations are different, and the omental tissue is low. The density is similar to that of adipose tissue, and the density of the stomach, intestines, kidneys, and spleen is uneven, and the gas sample has a low density shadow.
8.MRI
Can fully display complications, soft tissue swelling in the anterior mediastinum of the neck, effusion, tracheal displacement, neck, thoracic vertebrae fractures are clear, sensitive to the mediastinal abscess, pleural effusion, MRI signal unevenness at the time of sputum, can show lesions Relationship with His Majesty.
Diagnosis
Diagnosis and diagnosis of esophageal perforation
Early diagnosis
Timely and correct handling is the key to reducing mortality.
Clinical manifestation
The subcutaneous emphysema from the neck should be suspected of perforation of the esophagus, and a chest X-ray should be performed.
2. Auxiliary inspection
X-ray chest and abdomen showed mediastinal emphysema, liquid pneumothorax, pneumoperitoneum is an important evidence for the diagnosis of esophageal rupture; esophageal angiography can show a positive diagnosis if contrast agent spillover, but negative results can not rule out the possibility of perforation, repeat for suspicious cases an examination.
In the diagnosis, in addition to the diagnosis of perforation, the location and size of the perforation should also be known, which is very helpful for the formulation of the treatment plan.
Differential diagnosis
1. Neck esophageal perforation should be differentiated from instrumental examination of damaged or unperforated esophageal foreign body: neck esophageal perforation, although neck pain and sensation, can be exacerbated when swallowing or neck activity, but the sternocleidomastoid muscle before examination The edge often has tenderness, local swelling and subcutaneous emphysema, body temperature and white blood cell count gradually increase, X-ray film found that there is free gas in the cervical fascia.
2. The perforation of the lower esophagus needs to be differentiated from the perforation of the stomach and duodenum: the upper abdomen muscle tension often occurs after the perforation of the lower esophagus. The pain can be aggravated by the mediastinal inflammation of the spine, and the infection can affect the pleura and can cause shoulder pain.
