What Are the Different Causes of Esophagus Damage?

Esophageal injury is a disease that is mainly caused by esophageal rupture and perforation caused by equipment or foreign bodies. If not treated in time, acute mediastinitis, esophageal pleural fistula may occur, and it may cause death. According to the site of esophageal injury, it is divided into cervical esophageal injury, chest esophageal injury and abdominal esophageal injury.

Basic Information

English name

esophageal injury

Visiting department

Gastroenterology

Common locations

esophagus

Common causes

Caused by a device or foreign body

Common symptoms

Esophageal rupture, perforation

Causes of esophageal injury

The esophagus can be damaged by a number of different causes, and is largely divided into mechanical damage and chemical damage according to the cause of the damage. Mechanical injury can be divided into intracavity injury and extracavity injury. In recent years, with the rapid increase in the number of cases diagnosed and treated with instruments in the esophagus, the proportion of iatrogenic esophageal injuries in such diseases has also increased.

Clinical manifestations of esophageal injury

Neck esophagus perforation

Perforation of the esophagus of the neck often occurs in the thin posterior wall of the esophagus. The prevertebral fascia attached to the esophagus can limit the spread of pollution to the side. In the first few hours of the perforation, there may be no inflammation in the neck. After a few hours, the fluid in the mouth or stomach enters the esophageal space through the perforation and enters the mediastinum along the plane of the esophagus. Bloody stomach contents and dyspnea. Physical examination revealed that the patient was fragile, with various degrees of dyspnea. Coarse, noisy breathing sounds from nasal breathing are usually heard. Neck palpation revealed a stiff neck and twitching due to subcutaneous emphysema. Symptoms of systemic infection often occur after 24 hours.

2. Chest esophagus perforation

Thoracic esophageal perforation directly causes mediastinal contamination, and mediastinal emphysema and mediastinitis occur rapidly. This inflammatory process and large accumulation of body fluids caused by esophageal perforation are clinically manifested as severe pain in one thorax, accompanied by exacerbation during breathing, and radiating to the scapular region. In the perforated area, there is clear difficulty in swallowing, low blood volume, increased body temperature, and increased heart rate, and the increased heart rate is not proportional to the increase in body temperature. Symptoms of systemic infection, dyspnea. Physical examination revealed that patients had symptoms of poisoning to varying degrees. They did not dare to breathe hard and heard snoring sounds at the base of the lungs. When holding their breath, they could hear mediastinal rubbing sounds or twisting sounds with each heartbeat. The root of the neck or the anterior chest wall touches the subcutaneous gas. When the perforation breaks into the pleural cavity on one side, the signs of the liquid pneumothorax appear to varying degrees. Percussion on the upper side of the affected chest showed drum sounds, dullness on the lower side, and respiratory sounds on the affected side disappeared. A small number of cases can develop tension pneumothorax with tracheal displacement and mediastinal compression. The inflammation of the mediastinum and thorax stimulates the diaphragm, which can manifest as abdominal pain, upper abdominal muscle tension, and abdominal tenderness.

3. Perforation of abdominal esophagus

Injury to the abdominal cavity of the esophagus is rare. Once the injury occurs, the fluid in the stomach enters the free abdominal cavity, which mainly causes contamination of the abdominal cavity. The clinical manifestations are symptoms and signs of acute peritonitis. Sometimes this contamination may not be in the abdominal cavity but in the retroperitoneum, which will make diagnosis more difficult. This is because the esophagus of the abdominal cavity is adjacent to the diaphragm. It is a typical feature of upper abdominal pain and blunt sternum and radiating to the shoulder.

Esophageal injury examination

1. X-ray inspection

According to the location and cause of the perforation, a plain radiograph is performed. The neck perforation can find that the plane of the neck fascia contains gas, the trachea is displaced, the space behind the esophagus is widened, and the normal cervical physiological curvature disappears. In some patients, gas level may be found in the posterior esophageal space, emphysema in the neck or mediastinum, and pneumothorax and pneumoperitoneum. When the esophagus of the chest was perforated, the mediastinum was widened. There was gas or gas-liquid level in the mediastinum and gas-liquid level in the thorax. Free gas can be found under abdominal esophageal perforation.

Esophageal angiography

In general, patients are allowed to use esophageal angiography to confirm the diagnosis. For patients with esophageal perforation indicated by ordinary X-rays, esophageal angiography is also used to determine the size and location of the perforation. It should be noted that despite the use of angiography as a routine diagnostic tool, there are still 10% false negatives.

3. Gastroscopy

It has important diagnostic value for esophageal injury caused by chest trauma and foreign body. When the esophageal angiography is negative, sometimes the situation of esophageal injury can be directly seen with gastroscope, and it can provide accurate positioning and understand the pollution. The results of esophagoscopy also help in the choice of treatment.

4.CT inspection

The diagnosis of esophageal perforation should be considered when the CT image has the following signs: There is gas in the soft tissue of the mediastinum surrounding the esophagus. The pus cavity in the mediastinum or chest is close to the esophagus. The inflated esophagus communicates with a lumen filled with fluid adjacent to or adjacent to the mediastinum. Pleural effusion, especially left pleural effusion, further suggests the possibility of esophageal perforation.

5. Other

Patients with esophageal perforation due to saliva, gastric juice, and a large amount of digestive fluid enter the chest cavity. When performing a diagnostic thoracentesis, the pH of the chest fluid is lower than 6.0, and the content of amylase is increased. . In patients with suspected esophageal injury, a small amount of methylene blue can be seen in the drainage thoracentesis, which is also helpful for diagnosis.

Diagnosis of esophageal injury

All patients with neck, chest, or abdominal pain following intraesophageal instrumentation are considered to have the possibility of esophageal perforation. In the case of Mackler's triad, that is, vomiting, lower chest pain, and subcutaneous emphysema of the lower neck, the possibility of esophageal perforation should be promptly suspected, and further examination should be done. Chest trauma, especially in patients with trauma near the esophagus, should be routinely checked for esophageal damage. Combining relevant medical history, symptoms, signs and necessary auxiliary examinations can make timely and correct diagnosis.

Esophageal injury complications

May be complicated by purulent inflammation in the chest and peritoneal inflammation.

Esophageal injury treatment

1. Principles of surgical treatment

Remove all inflammation and necrotic tissue. According to the different parts, the perforation is closed accurately by appropriate methods; the distal obstruction of the esophageal perforation is corrected and removed. When the injury occurs near the esophageal obstruction or at the site of the obstruction, or when the diagnosis is too late (generally> 24 hours), repairing the injured esophagus directly is contraindicated.

2. Surgery plan

(1) Perforation of the neck is small. Perforation of the neck and esophagus is often performed only by placing a drainage beside the perforation, and the fistula can be closed by itself without further surgery.

(2) The middle and upper sections of the esophagus can be perforated into the thorax through the intercostal space, and the lower section can be perforated into the thoracic cavity through the intercostal space. Chest, according to which side of the thoracic cavity the esophagus breaks into, the chest should be opened from which side to facilitate surgical treatment.

(3) Abdominal perforation If there is no contamination in the thorax, surgical control can be performed directly through the midline incision of the upper abdomen. No matter where the perforation is, after the esophagus is exposed, methylene blue or gas can be injected into the esophageal cavity through a catheter in the esophagus to determine the perforation site.

3. Surgery method

(1) Drainage Effective drainage is essential, especially in cases of extensive inflammation and poor general conditions, and drainage tubes should be placed under CT guidance if necessary. This method is effective in patients with neck perforation and chest perforation.

(2) For patients diagnosed with primary suture in the early stage, when surgical indications are available, emergency surgery should be performed to repair the perforated esophagus. One-stage closure is best in healthy esophageal tissue. When there is a distal obstruction, simple one-stage closure is not effective, and the obstruction must be resolved at the same time.

(3) Reinforced suture Due to the possibility of cracking and fistula in the primary suture esophageal injury, especially when the patient has been separated for several hours from the perforation to the treatment, it is necessary to use the reinforced suture to close the esophageal perforation.

(4) Simultaneous treatment of esophageal disease. In the case of patients who can undergo surgery and the diseased esophagus can be removed, the best treatment is to surgically remove the diseased esophagus. After esophagectomy, whether to rebuild the digestive tract in the first or second stage depends on the situation of the contamination and the situation of the patient.

(5) External esophageal surgery External or esophageal surgery has been rarely used in recent years. Only when the patient's nutritional status is extremely poor, the above-mentioned methods are not suitable or ineffective in cases, the external use of the neck esophagus Ostomy or gastrostomy decompression.

Prognosis of esophageal injury

The factors that cause death after esophageal perforation are affected by the cause of perforation, the location of the esophagus, whether there are lesions in the esophagus, and whether timely treatment and treatment methods are available. Early and timely diagnosis, most patients treated correctly have a good prognosis.