Esophageal foreign bodies - Diagnosis

Diagnosis of foreign bodies in the esophagus is based on anamnesis data, clinical features at different levels of fixation of foreign bodies in the esophagus, X-ray and endoscopic examination of the esophagus and surrounding tissues. Significant diagnostic difficulties arise in infants and young children due to the possibility of asymptomatic penetration and presence in the esophagus of foreign bodies swallowed in the absence of parents, taking into account the insufficient sensitivity of the esophageal mucosa, weak radiopacity of the tissues of the neck area, anxiety of children during examination. Pediatricians believe that the etiology of such symptoms as hiccups, vomiting, dysphagia in a child is errors in the nutrition of children, dyspepsia, helminthic invasion.

Diagnosis of foreign bodies in the esophagus begins with questioning and examining the victim. A typical indication of foreign body ingestion is the patient's statement that at the moment of swallowing liquid (usually) food or a food bolus, a sensation of "stabbing" pain and distension behind the breastbone arose. However, this symptom is not a reliable indication that the foreign body has stopped in the esophagus. If the intensity of the pain does not subside, but, on the contrary, spontaneously increases and worsens with movements in the neck or torso, then this may indicate the introduction of a foreign body. The forced position of the head and torso at rest, characteristic head movements during swallowing movements should increase suspicions of the presence of an introduced foreign body. Regurgitation of saliva and swallowed food may also indicate the presence of a foreign body, but it may also be caused by a reflex spasm of the esophagus, which occurs as a result of damage to its wall by a transit foreign body that has passed into the stomach. These and other physical signs are only indirect (secondary) symptoms that do not allow us to confirm the presence of a foreign body in the esophagus. A reliable diagnostic result can be obtained by X-ray examination. However, even with this fairly objective method of identifying a foreign body in the esophagus, it is not always possible to obtain a reliable result. Only with radiopaque foreign bodies of an identifiable shape (for example, a safety pin, a nail, a denture), visualized in the lumen of the esophagus, can we confirm the presence of foreign bodies.

The anamnesis determines the probable nature of the foreign body, the duration of its presence in the esophagus, the sequence of development of clinical data indicating the possibility of complications, the nature and extent of previously provided medical care or other type of care (parents sometimes try to remove the foreign body themselves, causing significant trauma to the laryngopharynx with their fingers). Of great importance are anamnestic data on esophageal diseases preceding the ingestion of a foreign body (congenital reflux, esophageal diverticula, chemical burns, previous surgical interventions on the esophagus, etc.) to prevent complications during removal of the foreign body.

Physiological examination

Palpation of the neck area, simple and contrast radiography of the esophagus. Contrast foreign bodies are visible during plain fluoroscopy and chest radiography. If there is a suspicion of swallowing a non-contrast foreign body, a study is performed with a contrast agent (the patient is given one teaspoon or dessert spoon of thick barium suspension, then he takes 2-3 sips of water, normally the water washes away the barium, but if there is a foreign body, part of the contrast agent is retained on it - the method of SV Ivanova-Podobed). If the foreign body is localized in the cervical esophagus, lateral radiography of the laryngopharynx is performed in the projection of G.M. Zemtsov, which also allows diagnosing concomitant inflammatory changes in the periesophageal region. When non-contrasting foreign bodies are localized in the thoracic and diaphragmatic sections of the esophagus, the “cast symptom” is determined - pendulum-like movements of the contrast suspension - upward movement when swallowing the contrast fixed on the foreign body.

The diagnosis of foreign bodies in the stenotic esophagus is facilitated by: visualization of the suprastenotic expansion of the esophagus with very weak peristalsis due to its atony; indications of previous surgeries, burns, injuries; correction of congenital atresia, probing and repeated retention of foreign bodies in the esophagus. The basis for making a preliminary diagnosis of cicatricial stenosis of the esophagus is repeated retention in the esophagus of foreign bodies or objects that usually pass freely through the esophagus (small pieces of food, small coins), as well as indications in the anamnesis of esophageal damage. Large foreign bodies are accompanied by food blockage above their localization, which has the form of a local expansion of the prevertebral soft tissues, a horizontal level of fluid with air located above it in the form of a triangle.

When diagnosing foreign bodies in the esophagus, such techniques as swallowing bread crusts to detect a pain reaction, a test with a sip of water (the patient is asked to drink half a glass of water in one gulp and if there is no difficulty or pain, a conclusion is made about the absence of a foreign body) and an X-ray examination using cotton wool balls soaked in a barium suspension (the so-called Frankel test) are unacceptable.

Laboratory research

Commonly accepted clinical tests to clarify the severity of inflammatory phenomena.

Instrumental research

Pharyngoscopy, mirror laryngoscopy, endoscopy (rigid endoscopy and fibroendoscopy).

When non-radiographically contrasting objects are introduced into the esophagus, the results of X-ray diagnostics may be questionable, especially when small objects, fish bones, and thin plastic plates get stuck. When making an X-ray diagnosis, it should be borne in mind that the majority (70-80%) of such objects get stuck in the laryngopharynx and cervical esophagus. Larger foreign bodies are fixed in the middle sections of the esophagus.

To detect radiopaque foreign bodies, various methods are used depending on the level of the foreign bodies. Thus, to detect foreign bodies in the cervical esophagus, the method proposed by S.I. Ivanova (1932) gives fairly reliable results: the patient is asked to take 1-2 sips of a barium sulfate suspension of medium density directly during fluoroscopy (preferably in the presence of an endoscopist). Both the act of swallowing and the movement of the contrast mixture along the esophagus are observed. The study is carried out in the first and second oblique projections. In the presence of foreign bodies, a complete or partial retention of the contrast agent is noted depending on the size, shape and location of the foreign bodies, while the radiopaque foreign body is enveloped in the contrast agent and becomes visible. Subsequent sips of water easily wash away the contrast mixture from the walls of the esophagus, while some of it remains on the foreign body, allowing the localization of foreign bodies to be determined. In this way, it is possible to detect more or less large foreign bodies with an uneven surface that retains the contrast agent, but small and smooth linear objects, such as needle-like fish bones, are usually not detected by this method. In these cases, it is recommended to perform radiography of the neck using a non-contrast method, the essence of which is that the X-ray tube is installed at a distance of 150 cm from the film (13x18 cm), located against the neck at a level from the lower edge of the lower jaw to the head of the shoulder at a distance of the width of the shoulder. The picture is taken at an anode voltage of 80-90 kV and a current of 50-60 mA with an exposure of 0.5-1 s with breath holding. According to the author, this method can detect the smallest fish bones and other low-contrast foreign bodies in the larynx, pharynx, and cervical esophagus. The author points out that when interpreting non-contrast radiography, age and gender characteristics of the larynx should be taken into account so as not to mistake areas of calcification of the laryngeal cartilage for foreign bodies, which usually occurs after 40 years in men and later in women.

In case of blind gunshot wounds of the pharynx, larynx or cervical esophagus, V.I. Voyachek proposed introducing a "metal landmark" - a probe - into the wound channel to determine the localization of foreign bodies. In X-ray diagnostics of foreign bodies in the cervical esophagus, as well as gunshot projectiles in the soft tissues of the neck, a number of factors should be taken into account, two of which are of the most important significance: the superposition of the shadow of foreign bodies on the shadow of the esophagus and the displacement of foreign bodies and, consequently, its shadow when turning the head. Taking these phenomena into account, K.L. Khilov (1951) proposed, in addition to the above-mentioned I and II oblique projections, to take a third picture with a radiopaque "probe" inserted into the wound channel in the position of the patient in which he will be during surgery. With the help of this technique, the localization of the foreign body in relation to the organs of the neck - the pharynx, larynx, trachea, esophagus - is specified. This method facilitates the use of induction probes during surgery, which, when inserted into the wound and approached by a metallic foreign body, produce a sound signal. Modern video surgical technology in combination with intraoperative fluoroscopy and Doppleroscopy allows detecting and removing a foreign body under visual control on a TV monitor screen.

To detect non-metallic foreign bodies in the presence of a communicating fistula or wound channel, it is advisable to use the fistulography method, first proposed in 1897 by A. Graff, who used a 10% iodine solution in glycerin as a radiographic contrast agent - a method of X-ray examination of fistula tracts. The main goal of this method is to identify the direction, size and shape of the fistula tract, its branches and to establish connections and relationships with pathological foci - an abscess cavity, an osteomyelitis focus, a sequestrum complicated by a purulent process, foreign bodies, neighboring organs. Oil solutions of organic iodine compounds or its water-soluble compounds (monocomponent drugs - Trazograph, Omnipaque, Ultravist-240; combined drugs - Urografin) are usually used as a contrast agent in fistulography. Before filling the fistula canal with one of the indicated preparations, a survey radiography of the area under study is performed in at least two projections.

After this, the edges of the fistula opening are lubricated with a 5-10% alcohol solution of iodine and the pathological contents present in it are aspirated from the fistula tract. The contrast agent is administered immediately before the examination in the X-ray room with the patient in a horizontal position. The contrast agent is preheated to 37°C and injected into the fistula tract slowly, without force, ensuring that the syringe plunger moves evenly without additional force, which will indicate that the contrast agent enters only the pathological cavities, without forming a false tract. If significant pain occurs during the administration of the contrast agent, the fistulography procedure should be performed under local anesthesia. To do this, 1-2 ml of a 2% solution of novocaine or 1 ml of ultracaine are injected into the fistula tract for 10 minutes, after which the remains of the anesthetic are aspirated and the contrast agent is administered. To hermetically seal the fistula opening with a syringe cannula (a needle is not used), it is necessary to put a special tip of S.D. Ternovsky on it or increase its diameter by winding a strip of adhesive tape. Having achieved tight filling of the fistula canal, its opening should be closed with adhesive tape. If at the moment of tight filling of the fistula there is suddenly an easier introduction of the contrast agent, this may mean either a rupture of the wall of the fistula canal with penetration of the contrast agent into the interstitial spaces, or that the contrast agent has reached the pathological cavity and has begun to penetrate into it. In modern conditions, the fistulography method can be used in CT and MRI.

Using radiography, it is possible to diagnose complications of esophageal perforations such as periesophagitis and phlegmon of the periesophageal tissue.

After diagnostic fluoroscopy, which serves as an indicative diagnostic tool for foreign bodies in the esophagus, esophagoscopy is performed, which is used to remove foreign bodies if they are detected. Therefore, when preparing for esophagoscopy, it is necessary to have a full set of instruments for this operation.

Esophagoscopy for foreign bodies in the esophagus is contraindicated only in the presence of reliable signs of perforation or rupture of the esophageal wall. If there is a suspicion of foreign bodies, esophagoscopy is performed with great caution by a doctor with sufficient experience in removing foreign bodies from the esophagus. Young doctors, before starting to perform esophagoscopy, are recommended to be trained in this complex and responsible procedure on special dummies. When performing esophagoscopy, the possibility of four main errors should be taken into account:

1. failure to recognize an existing foreign body;
2. erroneous “detection” of a foreign body, which is often taken to be fragments of damaged mucous membrane;
3. Mistaken identification of a foreign body in the esophagus as a foreign body in the trachea; the reason for this mistake is that a foreign body of significant volume can compress the trachea and cause symptoms characteristic of a foreign body in the trachea (difficulty breathing);
4. failure to recognize esophageal perforation; this error can be avoided with a thorough clinical and radiological examination of the patient, which reveals subcutaneous and mediastinal emphysema.

Laxatives are strictly prohibited for patients suspected of having a foreign body prolapse into the stomach. Such patients are subject to observation in a hospital. To facilitate the passage of a foreign body through the gastrointestinal tract, a diet with a high content of plant fiber is recommended. The passage of metallic foreign bodies through the gastrointestinal tract is monitored using several consecutive X-ray examinations at different times. It is also necessary to examine the patient's feces to ensure that the foreign body has come out.

Differential diagnostics

It is performed with congenital malformations of the esophagus and post-traumatic deformations of its lumen, neoplasms of the esophagus and adjacent organs.

Indications for consultation with other specialists

In the event of periesophageal complications, in cases of difficult removal of foreign bodies during rigid endoscopy or fibroendoscopy, and especially in cases of the need to remove a foreign body by esophagotomy, a consultation with a thoracic surgeon is necessary. In cases of severe complications, the nature and scope of detoxification therapy are agreed upon with a resuscitator.

If the patient has associated diseases of internal organs and systems, after consultation with a therapist and anesthesiologist, the type of anesthetic care is determined.

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