Examination of the esophagus

The study of complaints is of the greatest importance in the clinical diagnosis of diseases of the esophagus.

Dysphagia  is a difficulty in swallowing, passing food through the  esophagus. Pharyngeal dysphagia is a difficulty in swallowing a food lump (sometimes with a cough), it is usually caused by neuromuscular disorders. Esophageal dysphagia is characterized by progression of the process during weeks and months, a violation of the passage first of dense and then liquid food. The sensation of a lump in the throat or behind the breastbone, not associated with swallowing food (pseudodisphagia), is observed with stones in the gallbladder, heart disease, but more often with hysteria.

Painful swallowing  and passage of food  through the esophagus is a serious sign of various diseases of the esophagus. An eructation of the  food masses is  characterized by the involuntary appearance of gastric contents in the mouth. Often, it is accompanied by aspiration of food masses - getting them into the respiratory tract (choking with the appearance of a cough). Most often, aspiration of food masses with the development of pneumonia occurs in patients with alcoholism.

Burning and severe  pain behind the sternum,  indistinguishable from pain with angina and myocardial infarction, occur when throwing food from the stomach into the esophagus ( reflux ).

Physical methods of research

The study of the esophagus by means of physical methods is inaccessible. However, in the presence of the above complaints, a general examination and examination of other organs are carried out.

Inspection allows you to detect a reduction in diet and even general exhaustion associated with a violation of food ingestion in the stomach in cancer and  achalasia of the esophagus. There may be signs of a systemic disease, such as systemic scleroderma, in the form of characteristic amy- mia of the face, skin tightening, etc.

With a long-term narrowing of the esophagus, the part that is located higher, sometimes with the displacement of the adjacent part of the lungs, a decrease in their vital capacity and the development of respiratory insufficiency by a restrictive type occurs.

An objective examination of a patient suffering from a particular disorder of the esophagus is divided into general and local.

The general examination, in addition to the generally accepted methods, appointed by the appropriate specialist (gastroenterologist, surgeon, ENT doctor, etc.) includes examination of the patient, during which they pay attention to his behavior, reaction to questions asked, on complexion, nutritional status, visible mucous membranes, skin turgor, its color, dryness or humidity, body temperature. The extreme anxiety and corresponding grimace on the face, the forced position of the head or torso, inclined forward, indicate a pain syndrome that can be caused by the presence of foreign bodies, food obstruction, diverticulum, filled with food, emphysema of the mediastinum, periesophagitis, etc. In such cases the patient, as a rule, is tense, tries not to make unnecessary movements of the head or body, assumes a position in which pain in the chest (esophagus) is minimized.

The relaxed and passive state of the patient indicates a traumatic (interanic damage, burn) or septic (pereezophagitis or perforating foreign body complicated by mediastinitis) shock, internal bleeding, general intoxication in case of poisoning with an aggressive liquid.

The facial expression of the patient reflects his mental state and, in part, the nature of the disease. Pain sensations arising in severe pathological conditions of the esophagus, such as chemical burns, perforations, secondary esophagomediastinitis, cause the patient to fear, hopelessness of their situation and extreme concern. Sometimes with septicemia and severe injuries - a delusional state.

Mental disorders are observed, as a rule, with acute diseases and lesions of the esophagus, while in chronic stenoses the patients develop a state of depression, pessimism, indifference.

When examining the patient, the color of the face is assessed: pallor in traumatic shock, pale yellowish tinge in  esophageal  (gastric) and hypochromic anemia, facial redness with acute vulgar esophagitis, cyanoticity with volumetric processes in the esophagus and emphysema of the mediastinum (compression of the venous system, respiratory failure).

When examining the neck, attention is paid to the presence of soft tissue edema, which can occur with inflammation of the periviscous cellulose (differentiate from  Quincke's edema  - acute angioedema dizziness of the face, mainly lips and eyelids, neck, extremities and external genitalia, often also covering the tongue, mucous membrane cheeks, epiglottis, less often the lower parts of the larynx), on the dermal veins, the increased pattern of which may indicate the presence of cervical lymphadenopathy, a tumor or diverticulum of the esophagus. Strengthening of the venous pattern on the skin of the abdomen indicates the development of kavocaval collaterals due to compression of the vena cava (mediastinal tumor) or the presence of  varicose veins of the esophagus  with difficulty in venous outflow in the portal portal vein of the liver (cirrhosis of the liver). In the latter case, esophageal bleeding is often observed, and if the blood immediately enters the oral cavity, then it has a red color, if first it enters the stomach cavity, where it reacts with hydrochloric acid, and then regurgitates, it gets dark red, almost black color. Consequently, the dark color of the blood in the vomit may indicate not only gastric, but also esophageal bleeding.

Local examination of the esophagus includes indirect and direct methods. Indirect methods include palpation, percussion and auscultation; to direct - roentgenography,  esophagoscopy  and some others. Palpation is available only in the cervical esophagus, but at the same time on the way to the esophagus lie massive tissues and a number of organs that interfere with this manipulation. Palpate the side surfaces of the neck, immersing the fingers in the space between the lateral surface of the larynx and the anterior edge of the sternocleidomastoid muscle. In this area, painful points and foci, enlarged lymph nodes, air crepitation with emphysema of the cervical mediastinum, a tumor, sound phenomena during the evacuation of a diverticulum, etc. Can be found in this area. With percussion, it is possible to establish a change in the percussion tone, which, in emphysema or stenosis of the esophagus, acquires a tympanic shade, with a tumor - does not change or becomes more blunt. Auscultation gives an idea of the nature of passage through the esophagus of fluid and semi-liquid substances, while listening to the so-called swallowing noises.

Additional research methods

X-ray examination. It is very demonstrative and is often crucial to the diagnosis. In this case, the patient swallows the contrast mixture, and when passing through the esophagus, the mucous membrane, motor activity, changes in the esophagus contour can be examined: enlargement, retraction, irregularities (inflammatory changes, tumors).

X-ray examination of the esophagus, along with fibroesophagoscopy, is the most common method used in the diagnosis of diseases of this organ. There are a large number of methods that make up this method, which pursue various diagnostic purposes, such as teleradiography and teleradiography, which prevent the deformation of foreign bodies, or orthodiography, by which measurements are made between two X-ray contrast labels for the projection localization of deformities of the esophagus, its extensions or identification foreign bodies. Tomography, including CT, allows to determine the prevalence of the pathological process; using stereoradiography form a volumetric image and determine the localization of the pathological process in space. X-ray kohmography allows to register peristaltic movements of the esophagus and to detect their disturbances. Finally, CT and MRI allow us to obtain exhaustive tomographic information about the localization of the pathological process and the nature of the organic changes in its walls and surrounding tissues.

The esophagus is X-ray non-contrast. Sometimes with very "soft" radiation it is possible to visualize it in the form of a weak shadow with contoured edges. The esophagus becomes visible when there is accumulation of air in it or in the surrounding air, which can be observed in aerophagy, paretic expansion of the esophagus, emphysema of the cystophilic space. The origin of the latter may be due to perforation of the esophagus wall, gas infection of the mediastinum, etc.

For a good visualization of the esophagus, methods of artificial contrasting are used (introduction of air through the probe or the use of sodium bicarbonate, which, upon contact with hydrochloric acid of gastric juice, releases carbon dioxide coming from belching into the esophagus). However, barium sulfate is usually used as a contrast agent. Sometimes iodolipol is used. The use of radiopaque substances differing in their aggregate state pursues different goals, primarily such as determining the filling of the esophagus, its shape, luminal state, patency and evacuation function.

Of great importance in the diagnosis of diseases of the esophagus have special methods of studying regional lymph nodes. Thus, in certain, most often oncological diseases of the pharynx and upper parts of the esophagus, as well as in purulent and other inflammatory processes in this area, lymph nodes of the neck are involved in the pathological process, which, according to N.L. Petrova (1998), respond with a lymphadenopathic response to more than 50 described nosological forms, while at the same time the method of physical examination of the nature of lymphadenopathy can be differentiated only in 70% of cases. According to N.V. Zabolotskaya (1996), in patients older than 40 years, the proportion of malignant neoplasms among all possible lymphadenopathy is 60%.

Endoscopy. This is the most sensitive method of studying the esophagus. From the altered sections of the mucosa take material for histological and bacteriological studies. Changes in the esophagus associated with reflux can be studied visually.

An important indication for endoscopy is bleeding from the upper part of the digestive tract, which allows to detect varicose veins, esophageal cancer, etc.

Perfusion of the mucosa of the esophagus is carried out by introducing a special probe and alternately irrigation the lower third of the esophagus with a neutral or acidic (low pH) liquid. Unpleasant sensations, which the patient observes when sprinkling with acidic liquid, indicate the presence of pathology of the esophagus.

Esophageal manometry. This study is conducted to evaluate the contractile function of the muscles of the esophagus. In this case, using a catheter, special sensors are introduced, located at different levels of the esophagus. The patient is then offered to swallow the liquid. At the level of the lower esophageal sphincter, a pressure of 20 to 40 mm Hg normally develops. Art. The pressure can be higher, in addition, the ability of the sphincter to relax decreases with ahalasia of the esophagus.

Measurement of pH in the contents of the lower part of the esophagus allows to diagnose the presence of reflux, while the pH of the content decreases.

[1], [2], [3]