Download Chemical burns to the esophagus

TASHKENT MEDICAL ACADEMY
DEPARTMENT OF FACULTY AND HOSPITAL SURGERY OF
MEDICAL FACULTY
"CONFIRM"
Vice Rector of TMA
Professor Teshaev O.R.
_______________________
"27" august 2015.
Theme of the lecture
ESOPHAGEAL DISEASE
For the students of V course of the treatment faculty
Tashkent - 2015
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TASHKENT MEDICAL ACADEMY
DEPARTMENT OF FACULTY AND HOSPITAL SURGERY OF
MEDICAL FACULTY
"CONFIRM"
Dean of the medical faculty
Professor Zufarov P.S.
_______________________
"27" august 2015.
Theme of the lecture
ESOPHAGEAL DISEASE
For the students of V course of the treatment faculty
Considered and approved on
surgical meeting section of CPC
Protocol number 1
Of "27" august 2015.
Tashkent - 2015
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TECHNOLOGY of TRAINING
Number of student 60-120
Time – 90 minut
Form of lesson
Lecture – Visualization
Plan of the lecture 1. Anatomy, syntopy esophagus.
2. Methods of study of the esophagus.
3. Etiology, pathogenesis, classification, clinical features,
diagnosis, differential. diagnosis and treatment of achalasia
of cardia.
4. Classification, clinical manifestations, diagnosis and
treatment of esophageal diverticula
5. Burns of the esophagus: classification, clinical features,
diagnosis and first aid
The purpose of the training session: To introduce students with esophageal
disease, teach them to diagnose and familiarize with its treatment options.
Task of the teacher:
Learning outcomes:
1. Introduce with the anatomy of the Student should master:
esophagus.
1. Clinical anatomy of the
2. Introduce with the etiology, pathogenesis, esophagus.
classification, clinic, diagnosis, differential. 2.
Etiology,
pathogenesis,
diagnosis and treatment of achalasia of cardia. classification, clinical picture,
3. Introduce the classification, clinic, diagnosis, differential. diagnosis
diagnosis and treatment of esophageal and treatment of achalasia of
diverticula.
cardia
4. Introduce with burns of the esophagus, 3. Classification, clinical picture,
their classification, clinic, diagnosis and first diagnosis and treatment of
aid for them
esophageal diverticula.
4. Classification, clinical picture,
diagnosis and first aid for burns of
the esophagus.
Methods and techniques of
Lecture - Imaging Technology: quiz, focusing
trained
questions, the technique of "yes-no"
Learning tools
Laser projector, visual materials, information
technology
Forms of learning
Collective
Conditions of learning
Audience adapted to work with the audio video
equipment
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TECHNOLOGY CARD OF THE LECTURE
Stages, time
Stage 1
Introduction
(5 min)
Stage 2
actualization of
knowledge
(20 min)
Stage 3
Information
(55 min)
Stage 4
Final
(10 min)
Activities
Teachers
1.Notifies the theme, purpose,
expected results and lectures of his
plan
2.1. In order to update the
knowledge of the students asks
questions
focusing
repeat
knowledge of anatomy, normal and
pathological physiology.
1. What is the length of the
esophagus?
2. What are the physiological and
anatomical narrowing of the
esophagus, you know?
3. Which consists of layers of the
wall of the esophagus? Conducts
blitz poll.
2.2. Slide show and comments
3.1. Consistently presents the
material lectures on plan uses visual
materials
with
incremental
responses to questions focusing.
Focuses on key topics, offers to
write them down.
4.1. Asks a series of questions to
secure the material using certain
clinical situations.
1. Is there a difference between
achalasia
of
cardia
and
cardiospasm?
2. First aid for burns of the
esophagus acids?
4.2. Gives a task for independent
work: tumors of the esophagus.
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students
1.Listen
2.1.Respond to questions
2.2.Contains a study of
the slides
3.1. Discuss the content of
the proposed materials,
clarify, ask questions.
Write down the main
points.
4.1. Respond to questions
4.2. Listen, write.
The purpose of the lecture: To familiarize students with esophageal
diseases, their etiology, pathogenesis, classification, clinical features, differential
diagnosis, optimal treatment, rehabilitation patients.
The educational goal of the lecture: Lecture promotes the formation of a
professional's personality, upbringing diligence, consistency, responsibility and
perseverance in achieving goals, and approach the state in matters of treatment and
prevention of disease.
Objectives of the lecture:
1. Familiarize with the anatomy of the esophagus.
2. Familiarize with the etiology, pathogenesis, classification, clinic,
diagnosis, differential diagnosis and treatment of achalasia of cardia.
3. Introduce the classification, clinic, diagnosis and treatment of esophageal
diverticula.
4. Familiarize with burns of the esophagus, their classification, clinic,
diagnosis and first aid for them.
Brief justification lecture topics: Lately, more and more surgeons paid
esophageal diseases associated with certain success of his surgery. At the same
time, today, esophageal surgery is still one of the most difficult in the
gastrointestinal tract surgery. Helping blnym with burns of the esophagus, and
esophageal diverticula treatment of achalasia of cardia - nosology that illuminates
this lecture material.
Issues to be parsed with the time
1. Anatomical data of the esophagus - 10 min
2. Methods of study of the esophagus - 10 minutes
3. Burns esophagus - 25 minutes
4. Diverticula of the esophagus - 20 minutes
5. Achalasia of cardia - 25 minutes
Questions to the audience to provide feedback and to ascertain the goal
lectures
1. List the three anatomical esophagus
2. 3 What is narrowing of the esophagus normally
3. Why varicose veins rapologayutsya in n / 3 of the esophagus
4. Tactics GP burns the esophagus
5. What types of diverticula you know
6. What is achalasia of cardia
7. Complications bougienage esophagus
8. Types of operations for esophageal reconstruction after it burns
9. complications of diverticulitis
10. What are the most common and frequently-occurring symptoms in
diseases of the esophagus
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Content of the topic.
ANATOMICAL AND PHYSIOLOGICAL FEATURES.
Esophagus - a muscular tube that begins as a continuation of the pharynx
and ends cardio. It is located in the midline, but is deflected to the left in the
bottom of the neck and back to the center line near the carina. The lower chest
esophagus again deflected to the left and passes through a hiatal.
There are 3 areas of physiological narrowing of the esophagus. The top is
caused by narrowing of the cricopharyngeal muscle. Average narrowing due to
the intersection of the left main bronchus and aortic arch. The lowest restriction
is due to gastro-esophageal sphincter. This restriction can delay the ingestion of
foreign bodies and corrosive liquids because of their slow passage through these
areas.
Cervical esophagus has a length of about 5 cm, and descends between the
trachea and the spine to a level front suprasternal notch. Recurrent laryngeal
nerves are in the right and left furrows between the trachea and the esophagus.
On the left and right sides of the cervical esophagus are the fascia of the carotid
arteries and thyroid lobe. The length of the thoracic esophagus is approximately
20 cm. The top of the chest esophagus tightly in contact with the rear wall of the
trachea and prespinal fascia. Lower down on the bifurcation of the trachea are
the vagus nerves and esophageal nerve bundle located in close contact with the
vertebral bodies. The thoracic cavity thoracic duct is behind the esophagus,
azygos vein between the right and descending part of the thoracic aorta to the
left. Abdominal esophagus has a length of about 2 cm. This part of the esophagus
is under positive pressure medium abdomen.
Esophageal musculature consists of an external longitudinal and internal
circular layers. Upper esophagus (2-6 cm) contains only the striped muscle fibers.
Below this level, the esophagus is gradually becoming richer smooth muscle
fibers. Clinically, the most important violations of esophageal peristalsis involve
only the smooth muscles of the lower two thirds of the esophagus. The circular
muscle layer of the esophagus is thicker than the outer longitudinal layer. The
structure is similar to the circular muscle helix, resulting in esophageal peristalsis
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a vermicular movement, in contrast to the segmental and sequential
compression.
Cervical esophagus supplied with blood mainly from the inferior thyroid
artery. Thoracic receives blood supply from the bronchial arteries. Two
esophageal branches depart directly from the aorta. Abdominal esophagus
receives blood supply from the ascending branch of the left gastric artery and
from the lower diaphragmatic arteries. In the initial part of the esophagus artery
formed in the longitudinal beam, which increases the intramural vascular network
in the muscle and that submucosal layers. Esophageal veins empty into the
inferior thyroid vein in bronchial unpaired or hemiazygos, as well as in the crown
of Vienna. Venous plexus submucosal layer of the esophagus and stomach are in
close connection with each other and with the portal venous obstruction of the
communication functions as collateral for the blood flowing in the superior vena
cava through the azygos vein.
The parasympathetic innervation of the pharynx and esophagus is carried out
mainly through the vagus nerves. Cricopharyngeal sphincter and cervical
esophagus receive branches, from both recurrent laryngeal nerves. Damage to
these nerves violate not only the function of the vocal cords, but also the function
of cricopharyngeal sphincter, predisposing to pulmonary aspiration.
Visceral sensory afferent pain fibers esophagus complexed vagal and
sympathetic pathways also anatomically combined with visceral afferent sensory
fibers emanating from the heart. Hence, both bodies have similar
symptomatology.
The lymphatic system is located in the submucosal layer of the esophagus,
small enough and consists of a submucosal plexus. Lymph flow runs in the
longitudinal direction. In the upper two thirds of the esophagus lymph moves
mainly in cephalic direction in the lower third - in the caudal.
Classification of diseases of the esophagus
1. Malformations:
1. Congenital esophageal atresia and esophagotracheal fistulas.
2. Congenital esophageal stenosis.
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3. Congenital diaphragm membrane of the esophagus.
4. Congenital short esophagus.
5. Congenital esophageal cyst.
6. Anomalies vessels.
2. Damage:
1. Traumatic injuries: external and internal
2. Burns of the esophagus and their consequences
3. Diseases of the esophagus:
1. Diverticula: pulsion and traction
2. Inflammatory diseases: esophagitis
4. Tumors of the esophagus:
1. Benign tumors
2. Malignant tumors
5. Violation of esophageal motility (cardiospasm):
1. Achalasia
2. esophageal spasm.
Malformations of the esophagus
Detectability: found 1 in 7-8 million newborns. The most common complete
esophageal atresia combined tracheobronchial fistula: a proximal end of the
esophagus connected to the distal trachea.
Less common complete esophageal atresia without tracheobronchial fistula.
Clinic: the disease appears at birth. If swallowed newborn saliva, colostrum,
the liquid instantly arises respiratory failure, cyanosis. At full atresia without
esophagotracheal fistulas at the first feeding occurs belching, vomiting.
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Diagnosis:
Clinical manifestations
Probing the esophagus,
The contrast study of the esophagus with Gastrographine
Panoramic radiographs of the thoracic and abdominal cavity: signs of
atelectasis areas, signs of pneumonia (aspiration), the absence of gas in the
intestines. Gas in the intestines may be the case if there is a connection of the
lower segment of the esophagus with the trachea (fistula).
Treatment: If there are no signs of atelectasis, pneumonia - simultaneous
operations esophagotracheal fistulas closure and anastomosis of the upper and
lower segments of the esophagus. If the disease is complicated by aspiration
pneumonia, atelectasis in the lungs is carried out following treatment: in the
beginning impose gastrostomy, intensive therapy to improve, and then close the
fistula and make anastomosis between the upper and lower segment of the
esophagus.
When multiple malformations in newborns severely weakened output of the
esophagus to the proximal end of the neck, to avoid the accumulation of saliva in
it, and imposed gastrostomy feeding. After a few months of performing an
anastomosis. If it is impossible to compare the upper and lower segments of the
esophagus perform plastic.
Congenital esophageal stenosis
Typically, a stenosis is located at the level of the aortic constriction. Clinic:
hiatal hernia, esophagitis, achalasia. With a significant narrowing of the
esophagus occurs suprastenotic expansion of the esophagus. Symptoms usually
do not appear until the introduction of solid baby food diet food.
Diagnosis: Clinical manifestations, EGDF-scopy and contrast study of the
esophagus.
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Treatment: In most cases, the expansion by dilation of the esophagus or
bougienage. Surgical treatment is carried out in an unsuccessful conservative
treatment.
Congenital diaphragm membrane of the esophagus
The diaphragm consists of connective tissue, covered with keratinizing
epithelium. In this diaphragm often have holes through which can penetrate the
food. Almost always localized in the upper part of the esophagus, much less - an
average of department.
Clinic: the main clinical manifestation is dysphagia, which occurs when
administered in the diet of the child solid food. When large holes in the
membrane of food can fall into the stomach. Such patients are generally all
thoroughly chew than prevent jamming of food in the esophagus. The membrane
under the influence of food debris often inflamed
Diagnosis: Clinical manifestations, a contrast study of the esophagus.
Treatment: the gradual expansion of the esophagus probes of different
diameters. When the diaphragm completely covers the clearance necessary to
remove it under endoscopic control.
Congenital short esophagus
It is believed that the in utero development of the esophagus has been slow,
and part of the stomach, penetrating through the diaphragm forms a lower part
of the esophagus. Congenital short esophagus occurs in Marfan's syndrome,
found familial cases of the disease. Clinic: clinical manifestations are similar to
those of the sliding hiatal hernia - pain in the chest after eating, heartburn,
vomiting can be.
Diagnosis: Clinical manifestations, often differentiate congenital short
esophagus from sliding hiatal hernia can only be surgery, EGDF-skopy.
Treatment: symptomatology - surgical, usually in the absence of adhesions
esophagus and the aorta can restore the normal position of the esophagus and
stomach by stretching it.
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Congenital esophageal cyst
Cysts are placed intramural, paraesophageal. These are lined with bronchial
cysts, esophageal epithelium.
Clinic: cysts in children can cause cough, dysphagia, respiratory failure,
cyanosis. In adults cysts usually less than 4 cm, 4 cm if the clinical symptoms is the
same as in leiomyomas. Cysts can mediastinitis complicated by infection, bleeding
and malignancy.
Treatment: removal of a cyst in the fibrogastroscopy.
Traumatic injuries to the esophagus
Classification:
Internal (closed) - Damage from the mucosa.
Outdoor (open) by connective membrane or peritoneum. As a rule,
accompanied by damage to the body when the skin wounds of the neck, chest
and abdomen.
Etiological factors:
Iatrogenic diagnostic and therapeutic measures (EGDF, probing, and
nasogastric intubation cardiodiosis GIT), tracheostomy, intubation.
Esophageal injury during operations on the thorax, neck and stomach.
Foreign bodies.
Diseases of the esophagus, leading to perforation of its wall (tumors, ulcers,
burns, etc.).
Ruptures of the esophagus most often occur after vomiting (75%), and cough
stress syndrome Mallory-Weiss - gap esophageal mucosa that is manifested by
bleeding after a severe attack of vomiting. Surgical intervention is required in 10%
of cases; Boerhaave syndrome (syndrome Boerhaven) usually occurs above the
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transition of the esophagus into the stomach. The diagnosis proves to be true
presence of air in the left mediastinum. Shown immediate surgery.
Injuries to the neck, chest, abdomen, caused a cold or firearms.
Ruptures of the esophagus closed body injuries.
There are full and partial damage to the esophagus. Incomplete damage to
the gap in the range of one or more shells, but not the entire thickness of the
body.
Full damage - the entire depth of the wall of the organ. With the localization
in the cervical region is developing retroesophageal or necrotic abscess of the
neck; thoracic - mediastenit, while damage of the pleura - pleural effusion, the
pericardium - pericarditis, in the abdomen - peritonitis.
Clinic:
1. Pain along the esophagus.
2. Foreign body sensation in the esophagus.
3. Hypersalivation.
4. bloody vomit.
5. Subcutaneous emphysema.
6. Salivation through injury.
Diagnostics. X-rays: Review angiography (emphysema or mediastinal tissue
neck hydropneumothorax, pneumoperitoneum).
Contrast radiography (on the back side, on your stomach) - Define the size of
the defect and its location. EGDF-scopy under anesthesia.
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Fig.1. Rupture of the esophagus - chest X-ray in the frontal projection. The
accumulation of air in mediastinum.
Treatment. Conservative: complete exclusion of enteral nutrition, drug
correction of homeostasis, antibiotics directed action. Surgery: removal of the
defect.
• Radical surgery: the removal of a defect in the wall of the esophagus and
drainage circumesophageal fiber whatever access.
• Palliative operations: depending on the level of damage to perform
drainage cellulitis: the cervical and thoracic level to Th4-Th5 - mediastinotomy
neck side. In the lower third of the thoracic esophagus - the lower transabdominal
mediastinotomy by Savinykh. Gastrostomy performed postoperatively to facilitate
supply of the patient.
Foreign bodies of the esophagus
Various objects caught in the lumen of the esophagus or stomach, and often
unable to manually remove these bodies.
Causes: Foreign bodies can enter the esophagus and stomach during a meal
or as a result of accidental ingestion are in the mouth of various items (pins,
needles, nails). Children often swallow coins, toys, buttons. In the elderly into the
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esophagus and the stomach can get dentures. Patients with mental disorders are
swallowed spoons, forks, and other items. As the foreign body can be fish or meat
bones. It is not uncommon stuck in the esophagus of large pieces of meat. Most
often this occurs when the influence of alcohol and the elderly. The development
of the disease - the fixed foreign bodies in the esophagus causing inflammation of
its walls, violate swallowing. Foreign body of the esophagus can lead to
compromise the integrity of its walls, threatening death. In the presence of
foreign bodies, they may be the stomach for a long time does not manifest itself,
however, will eventually lead to various complications such as the formation of
gastric ulcers, its obstruction, bleeding.
Clinic:
1. Fear.
2. constant pain when swallowing or localized: in the throat, in the jugular
fossa, behind the breastbone.
3. Dysphagia caused by a spasm of the muscles of the esophagus and
inflammatory edema of its mucosa.
4. Regurgitation, until the complete obstruction of the esophagus.
Diagnosis: the presence of foreign bodies established on the basis of the
story, and patient complaints. Objective proof of a foreign body of the esophagus
or stomach is obtained by X-ray or endoscopy.
Treatment: Foreign bodies of the esophagus and stomach are removed by
endoscopy. If unsuccessful attempts endoscopic removal of foreign bodies are
removed surgically.
Chemical burns to the esophagus
Corrosives (acid and alkali) cause severe burns to the esophagus. Frequent
suicide attempts among adults and accidents in children, associated with the
intake of vinegar, alkalis or detergents (eg, bleach). The most dangerous strong
alkali used in the home. Less damaging effect have detergents, bleaches and
disinfectants, some medications. Acids cause more damage in the stomach than
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in the esophagus. Early appearance burns mouth (or lack thereof), and does not
reflect the extent of dysphagia damaging esophagus. Assessment of damage
requires urgent endoscopy. In the treatment of burns of the esophagus should
immediately appoint corticosteroids and broad spectrum antibiotics. Survivors
may develop strictures and esophageal carcinoma in long-term periods.
Pathogenesis. Acids cause coagulation necrosis of tissue-way vaniem dense
crust that prevents the penetration of substances and reduces the depth of its
penetration into the blood. Alkalis cause necrosis, which contributes to the
transfer and dissemination of alkali in the healthy parts. Alkali burns are
characterized by a deep and widespread lesions of the esophageal wall. Ingesting
a substance other than the local, and has a general toxic effect to the
development of multiple organ failure. There are 4 stages of pathological
changes: hyperemia and mucosal edema, necrosis and ulceration of the mucous
membranes, the formation of granulation tissue, scarring. The degree of
morphological changes depending on the concentration of caustic substance, its
quantity, the degree of filling of the stomach, the timing of first aid, the nature of
the received material.
Clinically, there are three degrees of burns of the esophagus:
I - hyperemia and mucosal edema
II - mucosal lesion and submucosa
III - Defeat all the shells of the esophagus
Clinic:
The acute stage (5-10 days): Pain in the mouth, throat, chest, epigastric.
Hypersalivation. Dysphagia. The shock in the next few hours after the injury. Burn
toxemia in a few hours begins to prevail.
Stage imaginary prosperity (7-30 days): as a result of rejection necrotic
esophageal tissue from around the end of the 1st week is somewhat looser.
Complications: esophageal bleeding, perforation of the wall of the esophagus, in
the presence of extensive wound surfaces develops sepsis.
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Stage of stricture formation (from 2 to 6 months, sometimes for years). On
the wall of the esophagus varying length sites. Wound surface covered with a
scab, bleed easily. Dysphagia can reach the degree of complete obstruction of the
esophagus. When higher strictures: laryngospasm, cough, dyspnea due to spillage
of food into the airways.
Treatment of burns:
1. Rinse mouth and stomach solutions antidotes.
2. Drinking plenty of fluids (water, milk), followed by vomiting.
3. Required early (the first time) Gastric lavage (liquid volume of age - from 1
to 5 l).
4. Intensive antishock therapy.
5. Sedatives (pipolfenum, suprastin).
6. detoxification therapy.
7. With the development of acute renal failure - methods extracorporal
blood purification (up to hemodialysis).
8. Infusion therapy under the control of diuresis (indication - forced diuresis),
antibiotic therapy.
9. corticosteroid therapy.
10. Drinking fish oil, vegetable oil.
11. In case of burns of 2-3 degrees early (7-8 days), respectively bougienage
of esophageal lumen.
Treatment of complications. Early probing of the esophagus during 1-1.5
months in combination with corticosteroids and Lydasum. At the stage of
formation of strictures the main method of treatment - probing.
Indications: bougienage is shown all patients with post-burn esophageal
strictures (if it is possible to navigate through the restriction of the metal
conductor). Contraindications: mediastinitis, bronchoesophageal fistula.
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Types bougienage:
1. "Blind" - through the mouth.
2. On hollow radiopaque metal wire-nick (most often).
3. Under the supervision of esophagoscopy. It is shown when there is of
making it difficult, during the conductor.
4. According to the principle "probing without end" (with gastrostomy in
patients with tortuous and multiple strictures).
5. Retrograde (gastrostomy).
Indications for surgery:
1. Complete obliteration of the lumen of the esophagus.
2. Repeated failed attempts of the bougie passed through the stricture.
3. Recurrence of stricture after bougienage.
4. esophageal-tracheal, esophageal-bronchial fistula.
5. The perforation of the esophagus during probing.
6. More than two years after the burn.
The types of operations:
1. In segmental strictures - partial esophagoplasty.
2. With extensive strictures - total esophagoplasty with anterosternal or
intrasternal location transplant from the small or large intestine.
Esophageal dysmotility
Esophageal achalasia. Achalasia of the esophagus, also called achalasia;
cardiospasm; megaesophagus. Achalasia (cardiospasm) neuromuscular diseases
of the esophagus, violation of passage of food masses in the stomach due to
persistent violations of reflex opening of the cardia in swallowing, changes in
motility and tone of the esophageal wall attenuation. The incidence in relation to
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other diseases of the esophagus from 3 to 20%. The first symptoms often occur at
the age of 20 to 40 years. More common in women.
Etiology and pathogenesis: etiological factors achalasia - congenital
malformations of the nervous apparatus of the esophagus (intermuscular
degeneration (S. auerbachii) plexus); with the emergence of constitutional
neurasthenia, neurogenic discoordination of esophageal motility; reflex
dysfunction of the esophagus; infectious and toxic lesions of nerve plexus
schischevoda and cardia. Authorizes factor is stress or prolonged emotional
stress.
Pathogenesis: the study of intraesophageal pressure in the esophagealgastric junction is detected sphincter (physiological cardia). In healthy people, it
alone is able tonic contraction and relaxes after swallowing. The main violation
defining symptoms is the lack of or insufficient relaxation of the cardia relaxation
after swallowing. A variety of reactions cardia (incomplete disclosure when
swallowing, and incomplete disclosure spasm, full achalasia, achalasia and spasm,
hypertonicity source, etc.) Are one source mechanism of violation of the
innervation of the esophageal wall. Cases of achalasia occurring with cardiac
sphincter hypertonicity, can not be regarded as a true "cardiospasm" as the
primary mechanism for violating the permeability of the cardia is not
hypertonicity sphincter relaxation and the absence of his swallowing. Increased
pressure in the physiological cardia here is secondary and due to its reaction to
the constant pressure of the filling content esophagus, scarring and inflammatory
changes in the tissue-foot terminal esophagus and the loss of elasticity.
If achalasia simultaneously change the tone and peristalsis of the esophagus.
Instead of spreading to the stomach peristaltic contractions appear
nepropulsivnye (not ensure passage) waves, they are joined by segmental
contraction of the esophageal wall. Food is long delayed in the esophagus and
into the stomach as a result of the mechanical opening of the cardia under the
influence of the hydrostatic pressure of the liquid column above it. Prolonged
stagnation food masses, saliva and mucus in the esophagus leading to a
significant expansion of its lumen, and the development of esophagitis
periesophagitis, which in turn aggravates motility disorders of the esophagus.
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Pathological Anatomy: in severe cases note the expansion in diameter of the
esophagus 15 to 18 cm, its elongation, whereupon he can take an S-shape. Its
capacity reaches 2.3 liters instead of 50-100 ml in healthy people. The distal
portion of the esophagus narrowed sharply, it detected dystrophy ganglion cells
and fibers intramural nerve plexus until their death. The muscle layer was
observed degeneration of muscle fibers, the proliferation of connective tissue,
particularly in the wall narrowed segment fibrosis endoneurium, vasodilation, the
appearance around the infiltration of lymphoid and plasma cells. In all layers of
the esophageal wall and surrounding tissues show signs of inflammation.
Esophageal mucosa hyperemic, edematous, sometimes ulcerated. More
pronounced changes in the vicinity of the narrowed area of the esophagus.
Clinic and diagnostics: for achalasia is characterized by a triad of symptoms:
dysphagia, regurgitation, pain. Dysphagia - basic and, in most cases the first
symptom of the disease. In some patients it occurs suddenly, as though among
full health, while others develop gradually. Strengthening of dysphagia in most
patients say after a nervous excitement, during a hasty meal, while taking a
dense, dry and poorly chewed food. Sometimes there is a paradoxical dysphagia:
dense food passes into the stomach is better than the liquid and semi-liquid. A
number of patients with achalasia, dysphagia depends on the temperature of
food: bad passes or does not pass the food warm and cold pass, or vice versa.
Patients gradually adapted to facilitate the passage of food into the stomach
through a number of techniques (walking, gymnastics, swallowing air and saliva,
drinking large amounts of warm water, and others.). Expressed cachexia when
achalasia are rare. Regurgitation with a small expansion of the esophagus occurs
after a few mouthfuls of food, with a significant expansion of the esophagus is a
rare, but abundant and caused severe spastic contractions of the esophagus that
occur when it is full. Regurgitation in the supine position and with a strong torso
caused by mechanical pressure on the contents of the esophagus sphincter
pharyngoesophageal and stretching.
Night regurgitation associated with some decrease in tone
pharyngoesophageal sphincter. Chest pain when achalasia have varied. They may
be associated with spasm of the esophageal muscles and eliminated taking
nitroglycerin, amyl nitrite, and atropine. However, the majority of patients pain
occur overflow esophagus and disappear after regurgitation or passage of food
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into the stomach. In some patients, there are attacks of spontaneous pain in the
chest on the type of pain crises. Such pain is more often observed in the initial
period of the disease, sometimes before the onset of dysphagia and regurgitation,
which can not always be removed by atropine or nitroglycerin, which suggests
their association with progressive dystrophic process in the intramural plexus of
the esophagus. Pain on an empty stomach or after vomiting often caused by
esophagitis and removed meal. Belching air, nausea, excessive salivation, burning
along the esophagus, bad breath and are conditioned esophagitis. In patients with
both acute and gradual onset symptoms progress over time: enhanced dysphagia,
regurgitation often occurs. Many patients are embarrassed of their lack, become
withdrawn, painfully touchy.
The most common complication of the disease is stagnant esophagitis, which
occurs when a long delay food masses in the esophagus. In mild cases, it appears
hyperemia and edema of the mucosa, more severe - presence of coarse and
uneven folds, erosions, ulcers, which are usually located slightly above the
narrowed area. In the future may develop bleeding, perforation of the esophagus,
periezofagit. Chronic esophagitis can cause cancer of the esophagus and cardia.
Complications of achalasia are often repeated aspiration pneumonia, lung
abscess, pulmonary fibrosis. Most often, they occur in children. We describe the
complications caused by compression of the esophagus advanced recurrent
nerve, the right main bronchus, superior vena cava, the vagus nerve, and others.
B.V. Peterovskiy identifies four stages of the disease:
Stage I - functional intermittent spasm of the cardia, the expansion of the
esophagus is not observed;
Stage II - stable spasm of the cardia with soft extension of the esophagus,
Stage III - scarring of muscle layers of the cardia with a pronounced
expansion of the esophagus,
Stage IV pronounced stenosis of the cardia with dilation of the esophagus,
often S-shaped with esophagitis.
The main methods of diagnosis of achalasia are rentgenologic study,
esophagoscopy, esophagotonokimography, pharmacological tests.
20
At chest X-ray in patients with achalasia identify additional bulging of the
right contour of the mediastinum, the liquid level in the projection of the
posterior mediastinum, the absence of a gas bubble stomach. The main
radiological signs of achalasia - narrowing of the terminal part of the esophagus
with a clear, smooth and elastic loops ("inverted flame candle", "mouse tail")
folds of the mucous membrane in the area of narrowing saved. The first sip of
barium can freely flow into the stomach and then the contrast mass lingers long
in the esophagus. Over barium suspension define a layer of liquid and food debris.
Expansion of the esophagus above the constriction it is expressed to different
degrees. A number of patients note elongation and curvature of the esophagus.
Fig. 2. Multiple segmental tertiary contraction of the esophagus - "corkscrew
esophagus."
Peristalsis of the esophagus in all patients dramatically impaired: the
reduction eased to have spastic character and lack of amplitude. With the
development of esophagitis seen changes in the relief of the mucous membrane
of the esophagus: grain, thickening and tortuosity of the folds.
Esophagoscopy allows you to confirm the diagnosis of achalasia, identify its
complications and to conduct a differential diagnosis with other diseases
associated with dysphagia. Endoscopic picture depends on the duration of the
disease. At the beginning of the disease esophagus expanded slightly, as the
21
disease progresses the lumen increasingly expanding and some patients become
crimped.
The mucosa shows signs of inflammation: fold thickened arteries and veins
dilated, often visible areas of hyperemia, erosion, leukoplakia, ulcerations.
Usually, the end of esophagoscopy manages to push through the narrowed area,
confirming mainly the functional nature of the changes in the esophagus. The
mucosa in the constriction is not changed often.
Esophagotonokimographic study - the main method for early diagnosis of
achalasia of the esophagus, as a violation of the contractile ability of the
esophagus and cardia physiological occur much earlier than the clinical symptoms
of the disease. The study was conducted by a special multi-channel probe with
rubber bulb, or "open" catheters, registering reductions and changes within the
esophagus, esophageal pressure.
Normally, after swallowing the esophagus extends peristaltic wave, card at
this moment is opened and the pressure is reduced. After passing through the
peristaltic wave cardia is closed again. If there is no reflex achalasia cardia
sphincter relaxation during swallowing, and intraluminal pressure remains on the
former numbers. Another characteristic feature is the motility disorders of the
esophagus: swallowing of various shapes and spastic contraction, a large number
of local - secondary contractions of the esophagus, which indicates esophagitis. In
all patients, along with spastic contractions noted a large number of propulsive
peristaltic contractions of the esophagus. In doubtful cases, to confirm the
diagnosis of achalasia using pharmacological tests. Nitroglycerin, amyl nitrite in
patients with achalasia of the esophagus and lower the tone of the physiological
cardiac sphincter, which facilitates the passage of the contents of the esophagus
to the stomach. Introduction cholinotropic drugs (acetylcholine, carbachol,
Meholah) stimulates the muscular layer of the esophageal wall and the cardiac
sphincter. At cardioesophageal cancer and organic stenosis of the esophagus both
samples are negative.
Treatment: conservative therapy for achalasia is used only in the initial
stages of the disease, as well as used as a supplement to cardiodiosis and in
preparing patients for surgery. Food should be mechanically and thermally gentle,
rich in protein, vitamins. Power fractional, the last meal 3-4 hours before
22
bedtime. Reduction of dysphagia in I-II stages of the disease can be achieved by
the use of drugs nitro - nitroglycerin, amyl nitrite. With symptoms of congestive
esophagitis use a weak solution of washing esophagus antiseptics. The
therapeutic effect was observed after physical therapy electrophoresis
(iontophoresis) with novocaine, deep diathermy in the region of the cardia, the
long-wave diathermy, etc.
The main treatment for achalasia - cardiodiosis which is forced tension and
partial laceration of muscles of the distal portion of the esophagus and cardia.
Cardiodiosis may be carried out at any stage. Contraindication to its use are:
portal hypertension with esophageal varices, expressed esophagitis, blood
diseases, accompanied by bleeding disorders.
The most widely currently received pneumatic cardiodilatator which includes
radiopaque rubber tube probe at the end of which is fixed a dumbbell shaped
balloon. The diameter of the cylinder 25 to 45 mm. The pressure in the system
creates a pear and control gauge. At the beginning of treatment used extenders
smaller and establish pressure of 180-200 mm Hg, then use a larger diameter
cylinders and gradually increase them to pressure 300-320 mmHg. Duration of
treatment stretching cardia 30-60, the gap between sessions 2-4 days. Usually
during stretching patients experience mild chest pain in the epigastric region.
After the procedure, patients prescribed bed rest and hunger for 2-3 hours until
the disappearance of pain.
The effectiveness of dilatation is judged not only by the subjective feelings of
the patient, but also according to X-ray and esophagotonokimographic research.
During cardiodiosis in the next few hours after the possible complications
(rupture of the esophagus with the development of mediastinitis, acute
esophageal-gastric bleeding), requiring urgent action.
The early complications include dilation and insufficiency of the cardia with
the development of severe reflux esophagitis. As soon as possible after
cardiodiosis excellent and good results say nearly 95% of the patients, but after a
few years in 30-70% of patients with a recurrence requiring repeat treatment.
Surgical treatment of achalasia is symptomatic and aims to eliminate obstruction
of the gastroesophageal junction.
23
The indications for it are:
1. inability to hold cardiodiosis,
2. The lack of therapeutic effect after repeated courses cardiodiosis,
3. The early diagnosis of esophageal ruptures occurring during the expansion
of the cardia,
4. expressed peptic stricture developed after distension of the cardia and not
amenable to conservative therapy and probing,
5. The dramatic expansion, S-shaped curvature of the esophagus combined
with scar changes in the cardia.
Undergo surgery 15-20% of patients with achalasia. Currently, of all
proposed operations are used only by those that are based on the idea
cardiomyotomy. Extramucosal cardioplastic by Geller made of abdominal access,
producing a longitudinal incision muscle membrane terminal esophagus on the
front and back walls for 8-10 cm. The operation combined with Geller’s
esophagofundoraphia or Nissen fundoplication for the prevention of peptic
esophagitis. The results of operations for achalasia depends on the degree of
preoperative esophageal changes (change of tone and motility, severity of
inflammation), as well as carefully executed plastic surgery.
The ratio of the frequency of cardiodiosis and cardiomyotomy is 3: 1, but
may change as a result of the widespread introduction of advanced techniques of
performance of these procedures - endoscopic and laparoscopic myotomy
cardiodiosis devoid of drawbacks of open surgery.
Esophagism
Esophagism (diffuse) - a disease of the esophagus caused by spastic
contractions of its walls during normal function of the cardia. Most often occurs in
men and mostly in middle-aged and elderly. 6% of all functional disorders of the
esophagus.
24
The etiology of a number of patients due to esophageal spasm viscerovisceral reflexes, and combined with other diseases (peptic ulcer disease, tumors
of the esophagus and stomach, cholecystitis, peptic esophagitis, hiatal hernia,
atherosclerosis, angina, etc.). Because of this he was called reflex (secondary)
esophageal spasm.
There are also idiopathic (primary) esophageal spasm, are caused by
dysfunction of the nervous system and innervation of the esophagus. Pathological
anatomy: macroscopic changes in the esophagus is missing or there are signs of
esophagitis, sometimes noted muscle membrane thickening of esophageal wall.
Microscopic examination revealed significant degenerative changes in the
branches of the vagus nerve innervating the esophagus. The nature of the nerve
trunks and plexuses of the esophagus when esophagospasm achalasia and
different, which confirms the independence of these diseases.
Clinic and diagnosis: clinical picture is dominated by pain behind the
breastbone that appear during the passage of food through the esophagus, have
different intensities, may radiate to the back, jaw, neck, arms and other.
Sometimes there is pain meal, then they can be difficult differentiate from pain
caused by angina. For esophageal spasm characterized by impermanence
dysphagia and often its paradoxical character, which allows to differentiate this
disease from cancer, esophageal stricture and achalasia, where the worst passes
dense food and water it brings relief. During severe spastic contractions of the
esophagus can be a regurgitation of small amounts of the newly ingested food
into his mouth. It is never abundant, eaten a few hours before regurgitation or
the day before.
X-rays reveal changes in the esophagus as a "rosary", "pseudodiverticulum",
"corkscrew". The diameter of the esophagus above and below the narrowed area
is not changed, the esophageal wall resilient longitudinal mucosal folds, uneven
and irregular peristalsis. Repeated radiographic studies usually stored one and the
same type of motility disorders.
Esophagoscopy with this disease and little information is only relevant to
exclude organic diseases of the esophagus, it is often difficult because of the
strong chest pain occurring during the study. Esophageal mucosa is not changed
or there are signs of inflammation.
25
Eszophagotonokimographic study reveals spastic contraction of the
esophagus in the form of waves of different shape and amplitude, both recorded
and peristaltic contractions. Constantly determined reflex relaxation of the
cardiac sphincter (cardia disclosure). Pharmacological test with acetylcholine and
carbachol negative. Patients with esophageal spasm often find hiatal hernia,
perhaps a combination of disease with esophageal diverticulum.
Complication of esophageal spasm is esophagitis, reflex angina attacks. Longterm course of the disease, dysphagia times it intensified, then disappear almost
completely. In secondary (reflex) dyskinesia esophageal its symptoms usually
disappear when curing the underlying disease. Ability to work, as a rule, are not
compromised.
Treatment: it should be directed to the normalization of esophageal motility.
Complex treatment of patients with idiopathic (primary) esophagism include the
appointment of a sparing diet, antispasmodic and sedative medications, vitamins,
physiotherapy. In the absence of a positive effect from conservative therapy
produces esophagomyotomy (similar to operation Geller) to the level of the aortic
arch.
Lack of cardia (chalasia)
The disease is associated with impaired closing function physiologists-cal
cardiac sphincter, which can lead to gastro-esophageal reflux disease, and the
development of functional and organic changes in the esophagus. The lower
esophageal sphincter has a "one-sided cross." To move the contents of the
esophagus through a card is sufficient pressure of 4 mm Hg. v. in the opposite
direction movement is possible only when the pressure to 80 mm Hg. Art.
Normally, the pressure in the physiological cardia higher than the bottom of the
esophagus and stomach, and is equal to an average of 22-28 mm Hg. Art. It is
caused by tonic contraction of circular muscle fibers, preventing gastroesophageal reflux.
Most importantly, the subdiaphragmatic portion of the physiological cardia,
which prevents reflux with significant differential pressure in the chest and
abdomen. Normal anatomical location of the esophagus with respect to the
26
diaphragm is very important for the proper functioning of the locking mechanism
of the physiological cardia. Ingress of gastric contents into the esophagus and
prevent the presence of "mucous outlet" in the gastroesophageal junction, acute
angle-branch block, the valve of Gubarev - mucosal folds at the junction of the
esophagus with the stomach, the reflex reflex cardia when subcardial irritation of
the stomach with food and . The most frequently (50% of patients) incompetence
of cardia, leading to reflux esophagitis and peptic ulcer of the esophagus
observed in hiatal hernia.
Gastroesophageal reflux disease
Under gastroesophageal reflux disease (GERD) refers to cases of pathological
casting stomach contents into the esophagus regardless arise with morphological
changes in the esophagus or not. The majority of patients from repeated casting
esophageal mucosa inflamed, developing reflux esophagitis (RE). GERD - the most
common gastroenterological diseases. ER frequency in the population is about 24%. Endoscopic examination of the upper gastrointestinal disease is found in 612% of cases, most often in patients older than 50 years.
The classification of reflux esophagitis (RE):
I. Primary
Primary disorders of the nervous and peptide (gastrin, histamine, motilin,
and others.) Regulation of motility of the esophagus and stomach.
II. Secondary
At hiatal hernia, pyloric stenosis, cholecystitis, large tumors in the abdomen
ascites, pregnancy after gastric resection, in scleroderma and other diseases.
III. By severity (endoscopic classification of Savary and Miller, 1978)
Stage 1 - redness and swelling of the mucous membrane of the distal
esophagus, erosion of the sensible.
Stage 2 - drain erosion, captures up to 50% of the mucosal surface of the
distal esophagus
27
Stage 3 - erosion and / or ulceration in almost all (50%) or the whole surface
of the mucosa of the distal esophagus
4th stage - deep ulcers, esophageal stenosis, the cylindrical epithelium of the
mucous metaplasia, its distal (Barrett's esophagitis).
.
A
B
C
Fig. 3. Reflux esophagitis deformation esophagus with hiatal hernia (A),
relatively low-grade reflux esophagitis with mild stricture (B) and the Berret’s
esophagus, stricture of esophageal-gastric junction and the associated
relatively large ulcer (B).
Syndrome of Berret esophagitis - cylindrical metaplasia (replacement of
stratified squamous epithelium) of the distal esophageal mucosa. It is considered
a precancerous condition of the esophagus. GERD refers to diseases with a
primary violation of esophageal motility and stomach. It helps to reduce the
appearance of the tone of the lower esophageal sphincter (LES), which is revealed
in almost 3/4 of patients (normal, he has thrown into the esophagus prevents
gastric contents). Reduced LES tone may be due to a breach of its nervous
28
regulation of smooth muscle fibers and defeat. Reduce or increase LES tone may
bioactive substances and peptides.
Pathogenic factors of GERD - increase intragastric pressure, weakening the
ability of the esophagus to the stomach return hit him the contents, slowing
gastric emptying, increased production of hydrochloric acid, weakening the
protective properties of the epithelium of the esophagus and others.
Some importance in recent years began to attach the esophagus colonization
particular microorganism - Helicobacter (Helicobacter pylori), which worsens
during GERD. Contribute to the emergence of GERD. In addition, working posture,
forcing to the torso, overweight, pregnancy, smoking and alcohol consumption,
medication (calcium channel blockers, anticholinergics, theophylline, betablockers), frequent consumption of chocolate, coffee, some fruit juices, pepper
and other spices.
Symptoms of GERD - heartburn and epigastric pain, or in the lower part of
the sternum, arising during a meal or immediately after it, belching air,
regurgitation. In 25-40% of patients have dysphagia, which often indicates a
connection of peptic stricture of the esophagus, but can be simply a
manifestation associated dyskinetic disorders.
By extraesophageal manifestations of GERD and OM refers getting
esophageal contents into the bronchi with the emergence of bronchospastic
syndrome. GERD may also lead to the development of recurrent aspiration
pneumonia and bronchitis, laryngitis, pharyngitis, destruction of tooth enamel.
Tactics of treatment. The treatment starts with a general events, referred to
as a lifestyle change. We recommend frequent and smaller meals, eating at least
3 hours before bedtime, the vertical position of the body after eating, with the
exception of coffee, chocolate, pepper, spicy food, alcohol, smoking cessation
medication, drugs, predisposing to gastroesophageal reflux disease (nitrates, Mcholinoblocers, antidepressants, sedatives, aminophylline), abstaining from
physical exercise associated with torso. Patients also are advised to 15-20 cm to
lift the head end of the bed.
Assign an antacid (Maalox, and others) that increase gastric pH, increase the
tone of the LES, reduce the amount of reflux quickly cropped pain and heartburn.
29
However, the use of antacids together with common actions makes only 20% of
patients with GERD.
An important place in the treatment given to drugs, normalizing
gastrointestinal motility (prokinetic). Widely used dopamine receptor blockers metoclopramide and domperidone. It should be borne in mind that drugs of metoclopramid, providing central action, capable of causing extrapyramidal
disorders, especially in children and the elderly. Such patients are not
recommended to assign.
Cisapride (koordinaks) does not affect the dopaminergic receptors. It
stimulates the release of acetylcholine in the intermuscular neural plexus
digestive tract by activating serotonin 5HT4 receptors. Increases tone NPC
improves oesophageal clearance, normalizes gastric emptying. In the treatment
of GERD sufferers cisapride highly effective at a daily dose of 30-40 mg.
Usefulness potent antisecretory agents (histamine H2 receptor blockers and
proton pump) is supported by data, according to which erosion of the esophageal
mucosa majority of patients heal only when during the day manages to maintain
the pH in the esophagus over 4. At the same dose of histamine H2 receptor 2
times higher (600 mg or ranitidine 80 mg famotidine per day). Proton pump
blockers are currently considered the most potent antisecretory drugs.
Omeprazole 40mg achieves esophageal erosions heal in 85-90% of patients,
including patients who do not respond to therapy with histamine H2 receptor
blockers.
If necessary, long-term maintenance receiving proton pump blockers
(omeprazole, lansoprazole, pantoprazole) is required to conduct a course of
eradication antibiotic therapy in case of pyloric helicobacter in gastric mucosa.
Such treatment can prevent the progression of atrophic gastritis in a long-term
use of proton pump blockers. In repeated gastrointestinal bleeding of peptic
esophageal strictures, Barrett's syndrome formation, combined with dysplasia of
the esophagus, as well as the ineffectiveness of conservative therapy surgical
treatment. Perform the Nissen fundoplication.
Operation is enveloping the abdominal wall esophagus fundus. The stomach
is fixed to the diaphragm around the esophageal opening multiple seams. Good
results were achieved in more than 90% operated.
30
Diverticula of the esophagus
Diverticulum of the esophagus - esophageal diverticulum limited wall. There
are pulsion and traction diverticula. Pulsion diverticula are formed as a result of
esophageal diverticulum wall under high pressure intraesophageal arising during
its contraction. Development factional diverticula associated with inflammation in
the surrounding tissues, and scarring, which pulled the wall of the esophagus
toward the affected organ (mediastinal lymphadenitis, chronic mediastinitis,
pleurisy).
Traction mechanism is observed in the early development of a diverticulum,
then join pulsion factors, resulting in a diverticulum becomes pulsion-traction.
The diverticula are divided depending on the location on pharyngoesophageal
(Zenker's) epibronchiale (bifurcation, esophageal) epiphrenal (epidiaphragmal).
There are true diverticula, the wall of which contains all the layers of the wall
of the esophagus, and are solely responsible, in the wall of which there is no
muscle layer. The vast majority of acquired diverticula, congenital diverticula are
rare. When motility disorders of the esophagus (esophageal spasm) observed
pseudodiverticulum arising only at esophageal reduction, relaxation of the
esophagus when they disappear. The diverticula are rare under the age of 30
years and often after 50 years; among patients with male-dominated. Most
diverticula are often in the thoracic esophagus.
Pathological anatomy: pharyngoesophageal (Zenker's) diverticula develop
slowly formed in the back of the throat, just above the entrance into the
esophagus, often in the Lanier- Gakkerman triangle where muscular coat of the
pharynx shows weak muscle bundles inferior pharyngeal constrictor muscle, at
least - in the Laymer triangle bounded above m.cricopharyngeus, and on the sides
- the longitudinal muscle fibers esophageal wall.
31
Fig. 4. Cricopharyngeal (Zenker's) diverticulum.
The main importance in the formation of a Zenker's diverticula achalasia
cricopharyngeal muscles (violation of the disclosure of the upper esophageal
sphincter in response to swallowing). Diverticula go down between the rear wall
of the esophagus and the spine, can be displaced by the side of the neck muscles.
Their magnitude is different, they have a wide mouth. Diverticular wall contains
muscle fibers are generally not adherent to the surrounding tissues, its inner
surface is covered with a mucous membrane of the pharynx, it may be on the
surface of erosion or scarring.
Most epibronchial diverticula are located on the front or left side wall of the
esophagus, they rarely exceed a diameter of 1-2 cm. The bottom of the
diverticulum is usually directed upwards and adherent to adjacent organs, the
wall has a structure of the esophageal wall. Cavity diverticulum widely reported
with the esophageal lumen. When diverticulitis its shell inflamed mucosa may be
eroded. Epiphrenal diverticula most patients are placed on the front or the right
side wall of the esophagus, have rounded or slightly elongated shape. Their
diameter is larger than epibronchial diverticula in the neck there is often a slight
taper. Even with the larger sizes in the diverticula are rarely observed delay and
the expansion of the food mass. The wall has a structure of the wall of the
esophagus, the muscular shell can be poorly expressed or absent. The mucosa in
32
most patients is not changed. Finger diverticula with neighboring authorities are
not usually marked.
Clinic and diagnostics: small pharyngoesophageal diverticulum manifested
feeling tickling, scratching throat, dry cough, foreign body sensation in the throat,
excessive salivation, sometimes spastic dysphagia. As the diverticulum filling it
with food may be accompanied by a gurgling noise when swallowing, lead to the
development of dysphagia varying degrees of severity, to the appearance of
protrusions on the neck during abduction of the head backwards. Flexing has a
soft consistency, decreases with pressure, after taking water on percussion over it
is possible to determine splashing. Possible spontaneous regurgitation of
undigested food from the lumen of the diverticulum at a certain position of the
patient, difficulty breathing due to compression of the trachea, the occurrence of
hoarseness in the compression of the recurrent laryngeal nerve. When eating in
patients may develop "a phenomenon of the blockade", which appears red face,
feeling short of breath, dizziness, fainting, disappearing after vomiting during long
delays in food diverticulum appears putrid breath. Most patients with disturbed
nutrition that causes them to depletion.
Epibronchial diverticula often characterizes asymptomatic possible effects of
dysphagia, pain in the chest or back. In chronic diverticulitis - a breakthrough in
the trachea, aspiration, developing pneumonia, lung abscess.
Epiphrenal diverticula as most patients are asymptomatic, but may manifest
pain behind the lower part of the sternum, aerophagia, nausea, vomiting,
shortness of breath reflex, heartbeat, bronchospasm symptoms of compression of
the esophagus and cardiospasm. The disease is slow, with no significant
progression.
Zenker's diverticulum may be complicated by the development of
diverticulitis, which in turn can cause cellulitis neck, mediastinitis, development of
esophageal fistula, sepsis. Regurgitation and aspiration of content diverticulum
lead to chronic bronchitis, repeated pneumonia, lung abscess. There may be
bleeding from eroded mucosa diverticulum, polyps develop in it, its walls
malignancy.
33
If a long delay in mass food epibronchial and epiphrenal diverticula can occur
complications of diverticulitis, mediastinal abscess with a breakthrough in the
bronchus, esophagus, pericardium, and other organs of the mediastinum, massive
bleeding Chronic diverticulitis predisposes to cancer. Pharyngoesophageal
diverticula can sometimes be detected by inspection and palpation of the neck.
The main method of diagnosis of esophageal diverticula is a contrast X-ray
examination, to establish the existence of a diverticulum, neck width, the length
of the delay in its barium, the degree of cross-esophageal diverticulum signs of
development in the polyp and cancer, the formation of esophageal-bronchial
fistulas and esophageal -mediastinal. Endoscopy allows you to establish the
presence of diverticula, discover ulceration of its mucous membranes, bleeding,
diagnose polyps or cancer in the diverticulum. Conduct research to be very
careful because of the possibility of perforation of a diverticulum.
Treatment at small sizes diverticula, without complications, absolute
contraindications to surgery should be conservative therapy to prevent delays in
the diverticulum food masses and reducing the possibility of diverticulitis. Food
should be a full, mechanically, chemically and thermally gentle. Patients
recommend eating good food chopped. After the meal, you should drink a few
sips of water, take the position that promotes emptying diverticulum. For large
amounts of diverticula sometimes necessary washing cavity diverticulum.
Indications for surgical treatment of esophageal diverticula: complications
(perforation, penetration, bleeding, stenosis, esophageal cancer, the
development of fistulas), large diverticula complicated with at least a short-term
delay in their food of the masses, the long delay in the diverticulum of food,
regardless of its size.
Depending on the location of the diverticulum choose surgical approach: the
pharyngoesophageal - cervical, when epibronchial - sided transthoracic at
epiphrenal - left-sided transthoracic. Apply diverticulectomy: isolated from the
surrounding tissues diverticulum neck to produce myotomy, dissected it and
sutured hole in the wall of the esophagus. With a significant muscle defect or
atrophy of the muscle fibers of the esophagus produce plastic restoration of its
wall flap of the diaphragm, the pleura. Intussusception is used only at small sizes
diverticula. The mortality rate after surgery is 1-1.5%.
34
Benign tumors and cysts of the esophagus
Benign tumors of the esophagus are rare. Pathological anatomy: the tumor in
relation to the wall of the esophagus may be intraluminal (polypoid), and
intramural (intramural). On histological structure of the tumor is divided into
epithelial (adenomatous polyps, papillomas) and non-epithelial (leiomyoma,
rhabdomyomas, fibroma, lipoma, hemangioma, neuromas, chondroma, myxoma,
etc..). Intraluminal tumor usually located in the proximal or distal esophageal
intramural - in the lower two-thirds of it. From intramural benign tumors of the
esophagus is the most common type of uterine leiomyoma, develops from
smooth muscle fibers.
Clinic and diagnosis: benign esophageal tumors grow slowly for a long time
do not cause clinical symptoms and are discovered by chance during X-ray
examination of the gastrointestinal tract.
Clinical manifestations of them depend on the level of localization, the
magnitude, and complications (ulceration, inflammation, pressure on adjacent.
Bodies). The most common symptom - a periodic, slowly increasing over the
years, dysphagia. Most often it is observed in intraluminal large tumors on the
long leg. When intramural tumors circularly handling esophagus, dysphagia may
be permanent, sometimes patients report pain, feeling of pressure in the chest or
overflow, dyspeptic symptoms. When tumors of the cervical esophagus, with long
stem, regurgitation may occur tumor development and asphyxia. If a polyp or
ulceration of esophageal mucosa damage, stretched over a large intramural
tumor may bleed. Cysts of the esophagus may fester. Due to the compression of
the tumor of the mediastinum (trachea, bronchi, heart, vagus nerves) may
experience cough, dyspnea, cyanosis, palpitations, pain in the heart, arrhythmias
and other disorders. Perhaps the malignant transformation of benign tumors of
the esophagus.
The diagnosis of a benign tumor of the esophagus is put on the analysis of
the clinical picture of the disease, these X-ray examination and esophagoscopy.
For benign tumors of the esophagus characterized by the following
radiological signs: a clear smooth contours filling defect, which is located on one
35
of the walls of the esophagus, the preservation of the relief of the mucosa and
the elasticity of the walls of the esophagus in the area of the defect, clear the
angle between the wall of the esophagus and the edge of the tumor (a symptom
of "cap"). When cinematic study of benign-education of the esophagus when
swallowing moves upward together with the wall of the esophagus.
To exclude external compression of the esophagus neoplasm originating
from the mediastinum, or abnormally large blood vessel located using
pneumomediastinography and aortography. All patients with benign tumors of
the esophagus shows esophagoscopy to clarify the nature of education, its
localization and extension, the state of the mucous membrane Esophagoscopy
reveals intraluminal tumor, inspect its foundation, ensure no rigidity walls of the
esophagus. Ulceration of the mucous membrane in the intramural benign tumors
and cysts of the esophagus is rare. A biopsy can be performed only if the
destruction of the mucous membrane and intraluminal tumors.
Treatment: benign tumors due to the possibility of bleeding, malignancy,
compression of the surrounding organs, surgical treatment. Tumors of the small
size on a thin stalk can be removed by using special esophagoscope and
electrocoagulation. When intraluminal tumors produce on a broad basis to the
site of excision of the esophageal wall. When intramural tumors and cysts of the
esophagus is almost always manage to produce their enucleation without
damaging the mucosa. Long-term results of operations are good.
Esophageal carcinoma
Esophageal cancer - the most common disease of the body is 80-90% of all
diseases of the esophagus. Among all malignant tumors of the esophagus cancer
is the eighth, and malignant tumors of the digestive tract - 3rd place after cancer
of the stomach and rectum. Most commonly affects the middle third of the
thoracic esophagus (40-60%), at least part of the tumor is localized in the upper
thoracic (10-15%) and lower thoracic (20-25%) departments.
Grossly, there are three forms of cancer:
36
1. scirrhous or infiltrative cancer, when the tumor infiltrates the wall of the
esophagus uniformly and without distinct border passes in normal tissue;
2. Ulcerative or medullary cancer - growing into the lumen of the esophagus,
easily breaks early metastasizes to regional lymph nodes and distant;
3-knotted or warty papillomatous cancer - has exofit growth, easily breaks
and bleeds; mixed forms of the tumor.
On histological structure it develops in 96% of squamous cell carcinoma,
adenocarcinoma, or much less undifferentiated carcinoma. The incidence - the
occurrence of esophageal cancer associated with the peculiarities of power, as
well as alcohol and tobacco smoking. Among the indigenous peoples of the North,
Siberia and Far East widespread use of very hot "brick" tea, frozen fish and meat,
hard pellets that are sometimes in the winter, too, are stored in frozen form. Such
a diet with irregular nutrition, as well as the abuse of alcohol or lead to
permanent injury to the esophagus and predisposition to cancer. There is a zone
of high incidence of esophageal cancer. It covers northern Iran, Central Asia,
Kazakhstan, Yakutia, some regions of China and Mongolia. In addition to these
areas, there is a very high incidence in several countries in South Africa. Increased
incidence of esophageal cancer in France and Brazil. India and the United States
among the black population. In most European countries, the tumor is relatively
rare (men - 4-7, 1-2 women per 100 000 population). In areas with a high
incidence of esophageal cancer is 5-10 times more common in persons of the
indigenous nationality, than the non-indigenous population. Such significant
differences may be related to the peculiarities of the nature of power, but we can
not exclude the influence of genetic factors. Risk factors for esophageal cancer is
recognized systematic contact with carcinogens, chronic radiation exposure,
excessive mechanical, thermal, chemical irritation of the esophagus cicatricial
narrowing of the esophagus chemical burns after his achalasia, hiatal hernia,
reflux esophagitis.
Precancerous diseases: Repeatedly repeated exposure to harmful factors
leads to microtraumas or thermal damage to the esophageal mucosa, causing
chronic esophagitis and support. Chronic esophagitis create conditions for
realization of the toxic effect of carcinogenic substances contained in tobacco
smoke and enters the food composition, often accompanied by epithelial
37
dysplasia of esophagus mucosa. By precancerous diseases also include peptic
ulcer of the esophagus, polyps and papillomas of the esophagus scar stricture,
dysphagia sideropenic (Plummer-Vinson syndrome).
Diagnosis: "Alarms" suggest the possibility of cancer of the esophagus are:
dysphagia any severity that occurred regardless of mechanical, thermal or
chemical injury of the esophagus; sense passage bolus, pain or discomfort along
the esophagus resulting from the ingestion; recurrent regurgitation or vomiting,
especially with blood; unjustly appeared hoarseness; racking cough that occurs
when fluid intake. Instrumental methods of research are crucial in detecting
cancer of the esophagus.
Fig. 5.
Endoscopic ultrasound of carcinoma in the
esophageal-gastric junction: T- transmural
tumor, Common - the aorta, the second concentric rings - artifacts from the endoluminal
probe in the esophagus,
X-ray examination of the esophagus detected: violation of the structure of
the mucous relief; filling defect detection; the shadow of the tumor site; the
absence of esophageal peristalsis. Features X-ray study increase with doublecontrast esophageal study under pneumomediastinum. Esophagoscopy must be
performed at the slightest suspicion of esophageal pathology. This is a direct
method of diagnosis of the tumor. Set the level of destruction, the shape of the
tumor, the degree of narrowing of the esophagus, the presence of decay or
bleeding from the tumor. During esophagoscopy taken material for cytological
and histological examination. The informativeness of these methods is very high.
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Fig. 6. Squamous cell carcinoma of the distal
esophagus
Staging of esophageal cancer is performed by generally accepted international
classification of esophageal cancer, which provides characterization of the tumor
system TNM.
The clinical picture. The clinical symptoms of esophageal cancer can be
divided into three groups: primary or local symptoms associated lesion esophageal
wall; secondary symptoms resulting from proliferation of tumor to adjacent organs
and tissues; common symptoms caused by intoxication and malnutrition.
The primary symptoms include dysphagia, chest pain, a feeling of fullness in
the chest, regurgitation of food (regurgitation), reinforced salivation. Almost all of
these symptoms indicate a sufficiently large propagation of the pathological
process of the esophagus.
Typical symptoms of cancer of the esophagus caused by the phenomenon of
obstruction. The most striking of these is dysphagia - difficulty in the passage of
food through the esophagus. Dysphagia caused by narrowing of the lumen of the
39
body of a growing tumor (mechanical dysphagia), but sometimes it depends on the
spasm in the overlying esophagus (dysphagia reflex). In most cases, dysphagia is
growing gradually.
At first it appears barely noticeable delays when passing through the
esophagus solid food. The patient feels as if a lump of solid food on its way
through the esophagus. The narrowing progresses, and soon the patient has to drink
a sip of water solid food or stop taking dishes. Later, after a few weeks or months
stops flowing semi-liquid food, and then the liquid. This consistent development of
dysphagia is not always observed. Sometimes, as a result of the collapse of the
tumor or medical treatment of esophageal patency partially or fully restored.
Improving the condition does not last long, and soon begins to progress again
dysphagia.
There are 5 degrees of dysphagia:
I degree - takes any food, but swallowing solid food experience discomfort
(burning, scratching, sometimes pain);
II degree - solid food lingers in the esophagus and passes with difficulty, it is
necessary to wash down solids with water;
III degree - solid food does not pass. When you try to swallow it appears
regurgitation. Patients fed liquid and semi-liquid food;
IV degree - the esophagus to pass only liquid;
V degree - the complete obstruction of the esophagus. Patients unable to
swallow a sip of water, does not pass even saliva.
Important to diagnose symptoms are: esophageal regurgitation of food and
vomiting. Regurgitation often caused by a spasm, it occurs immediately after a
meal. Esophageal vomiting seen in patients with severe stenosis, some time after
the meal. Regurgitation, along with other dyspepsia (belching, heartburn, nausea)
in some patients may appear the first symptom disease. In some cases, quite early
there salivating (hypersalivation), but more often it occurs at high-grade stenosis.
Hypersalivation treated as a protective reflex that facilitates food to overcome
obstacles.
Along with the listed symptoms esophageal cancer may be accompanied by
unpleasant or smelly breath, which is dependent on tumor lysis and putrefaction
above contraction and felt by the patient or detected by others.
Secondary symptoms are late manifestations of cancer of the esophagus. They
testify about the complications of the disease, due to which the process of the
esophageal wall. Secondary symptoms - a hoarseness, Horner's triad (cramps,
pseudoptosis, endophthalmitis), increase local lymphatic sites, bradycardia, cough,
change of voice sonority, vomiting, shortness of breath, choking with stridor.
Because of the common symptoms inherent malignant neoplasms of internal
organs, cancer of the esophagus observed a progressive loss of body weight, up to
cachexia, increasing general weakness, fatigue, anemia.
Treatment. Treatment options for esophageal cancer depends on the tumor
location, stage of the process, the presence of comorbidities good results of
40
surgical treatment can be expected in stage I of the disease, at least in the II and III
stages. However, esophageal cancer is rarely diagnosed early, most patients seek
help after six months after the first symptoms of the disease.
Inoperable patients come in for two reasons:
1) tumor sprouting adjacent organs - aorta, trachea, lung, metastasis to lymph
nodes of the second, third order and other organs (liver, lungs); the possibility of
removal of the tumor (resectability) in most patients become completely clear only
during the operation;
2) the presence of concomitant diseases of the heart, lungs, kidneys, liver and
other organs in the stage of decompensation.
In cancer of the cervical and thoracic esophagus tumor grows quickly into the
surrounding organs and early metastasizes. Cancer this localization more
successfully treated using radiation therapy. In cancer of the esophagus produce
middle chest surgery by Dobromyslov-Terek. From transpleural access remove the
thoracic esophagus and impose a gastrostomy. Subsequently (after 3-6 months)
creating an artificial esophagus of the colon or small intestine. In strong young
men can do the resection of the esophagus with anastomosis between the
imposition of the remaining part of the esophagus and the displaced in the right
pleural cavity of the stomach (the operation of Lewis). In cancer of the lower
thoracic esophagus operation of choice is resection of the esophagus with
simultaneous imposition of intrathoracic esophagogastric anastomosis at the aortic
arch, or at the level of her.
Good results from the combination of radiation and surgical treatment.
Preoperative radiotherapy is carried out in dose of 30-50 Gy (3000-5000 rad).
Acting on the primary lesion and possible foci of metastases-tion, radiation therapy
is designed to migrate from a tumor in questionable resectable resectable, to
eliminate accompanying inflammatory changes. Surgery is produced in 2-3 weeks
after the end of radiotherapy.
At unoperative tumor with contraindications to radical surgery produce
palliative intervention to restore patency of the esophagus, improve nutrition of the
patient. Palliative operations include: palliative resection of the tumor
recanalization with Mylar prosthesis (arthroplasty), the imposition of gastrostomy.
Radiation treatment is used as in the radical, and in palliative treatment of cancer
of the esophagus. The most favorable results were obtained using a high energy
source (gamma-therapy, braking radiation and fast electrons) that provide
settlement to the esophageal tumor high-dose radiation.
When squamous cell carcinoma of the upper third of the esophagus after the
imposition of gastrostomy patients underwent radical radiotherapy at a total dose
of 60-70 Gy (6000-7000 rad) at a daily dose of 1.5-2 Gy (150-200 rad). When
squamous cell carcinoma of the middle third of the esophagus patients impose a
gastrostomy tube, and then carry out palliative radiotherapy at a dose of 20-40 Gy
(2000-4000 rad) whose main goal is the removal of dysphagia, pain and slow the
progression of cancer. Treatment provides rapid clinical effect due to the removal
41
of perifocal inflammation and reduce tumor size. When esophageal
adenocarcinoma radiotherapy is ineffective. Radiation therapy is contraindicated in
severe diseases of the cardiovascular and respiratory systems, parenchymal organs,
central nervous system, the decay of the tumor, bleeding.
If you can not perform surgery or radiation therapy for cancer of the
esophagus can be used as a palliative chemotherapy (a combination of antimetabolites of pyrimidine series - 5-fluorouracil, or methotrexate and fluorofur
colhamini). Chemotherapy is a cancer of the esophagus to the present poor results
due to the low sensitivity of the tumor to the known anticancer drugs.
All patients with an inoperable form of cancer of the esophagus demonstrated
symptomatic therapy aimed at pain relief, elimination of malnutrition. Five-year
survival after radical surgery is less than 10%.
The recommended literature
I. Basis:
1. Хирургик касаликлар. Ш.И.Каримов, Тошкент, 2005.
2. Хирургические болезни. Ш.И. Каримов, Ташкент, 2005.
3. Chirurgik kasalliklar. Sh.I. Karimov. Toshkent, 2011.
4. Хирургик касаликлар. Ш.И.Каримов, Н.Х.Шамирзаев, Тошкент, 1995.
5. Хирургические болезни. Под ред.М.И.Кузина., Медицина, 2002.
6. Методическое пособие по госпитальной хирургии. Назыров Ф.Г. с
соав.Ташкент 2004г.
7. Клиническая хирургия. Под ред. Панцырева Ю.М. М. «Медицина»,
1988
8. Воробьев А. Справочник практического врача в 3х томах. 1990
9. Конден Р., Нейхус Л. Клиническая хирургия Москва. Практика 1998
10. Назиров Ф.Г., Денисов И.И., Улугбеков Э.Г. Справочникпутеводитель практикующего врача. Москва, 2000.
11. Петровский Б.В. ред. Руководство по хирургии (в 12 томах) М.
Медицина 1959-1966.
II. Additional:
12. Астапенко В.Г. Практическое руководство по хирургическим
болезням. Минск, 2004.
13. Савельев В.С. 50 лекции по хирургии. Москва 2004.
14. Диагностический справочник хирурга – Астафуров В.Н. 2003.
15. Лапароскопическая и торакоскопическая хирургия – Константин
Франтзайдес. 2000.
16. Здравый смысл в неотложной абдоминальной хирургии – Моше
Шайн.2003г
17. Неотложная абдоминальная хирургия – Майстренко Н.А.2002г
18. Абдоминальная хирургия – Григорян Р.А. В 2-х томах.2006г
42
19. Internet addresses on an employment theme: www.rmj.net,
www.consilium-medicum.com,
www.mediasphera.ru,
www.laparoscopy.ru,
www.ehpb.com,
www.
medmore.ru,
www.gastroportal.ru,
www.medilexicom.com, www.encicloperdia.com, www. omoc.su.
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