Foreign bodies of the esophagus: diagnosis

Diagnosis of foreign bodies of the esophagus is based on data of anamnesis, peculiarities of the clinical picture at different levels of fixation of foreign bodies in the esophagus, X-ray and endoscopic examination of the esophagus and surrounding tissues. Significant difficulties in diagnosis occur in infants and young children due to the possibility of asymptomatic penetration and stay in the esophagus of foreign bodies swallowed in the absence of parents, taking into account the lack of sensitivity of the mucous membrane of the esophagus, weak radiopaque tissue of the neck, anxiety of children during the examination. The etiology of such symptoms as hiccups, vomiting, dysphagia in a child, pediatricians consider inaccuracies in children's nutrition, dyspepsia, and helminthic infestation.

Diagnosis of foreign bodies of the esophagus begins with a survey and examination of the victim. A typical indication of ingestion of a foreign body is the patient's statement that at the moment of a sip of liquid (more often) food or food lump, there was a sensation of "stitching" pain and raspryaniya behind the sternum. However, this sign is not a reliable indication that the foreign body has stopped in the esophagus. If the intensity of pain does not subside, but, on the contrary, spontaneously intensifies and aggravates with movements in the neck or trunk, then this may indicate the introduction of a foreign body. The forced position of the head and trunk in rest, the characteristic movements of the head with swallowing movements should increase suspicions for the presence of an introduced foreign body. Regurgitation of saliva and swallowed food can also indicate the presence of a foreign body, but it can also be caused by the reflex spasm of the esophagus, which arose as a result of damage to its wall by a transit foreign body that passed into the stomach. These and other physical signs are only indirect (secondary) symptoms, not allowing 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 rather objective method of detecting a foreign body of the esophagus, it is not always possible to obtain a reliable result. Only with radiopaque foreign bodies of an identifiable form (for example, an English pin, a nail, a denture), visualized in the lumen of the esophagus, can we ascertain the presence of foreign bodies.

The history of the foreign body is determined by the alleged nature of the foreign body, the duration of its stay in the esophagus, the sequence of development of clinical data indicating the possible development of complications, the nature and volume of previously provided medical assistance or other assistance (parents sometimes try to remove the foreign body themselves, causing a significant injury to the area laryngopharynx). Of great importance are the anamnestic data on diseases of the esophagus, preceding ingestion of the foreign body (congenital reflux, esophageal diverticula, chemical burns, previous surgical interventions on the esophagus, etc.) to prevent complications during removal of the foreign body.

Phyical examination

Palpation of the neck region, radiography of the esophagus is simple and contrasting. Contrasting foreign bodies can be seen with a review of fluoroscopy and chest X-ray. If you suspect a swallowing of a non-contrast foreign body, a study is done with a contrast agent (the patient is given one teaspoonful or a dessert spoon of a thick barium suspension, then he takes 2-3 drops of water, normally water flushes the barium, but in the presence of a foreign body, a part of the contrast medium lingers on it - the method of St. Ivanova-Podobed). When the foreign body is localized in the cervical esophagus, a lateral x-ray of the laryngopharynx is performed in the projection of G.M. Zemtsov, which also allows to diagnose concomitant inflammatory changes in the vicinity of the esophagus. With the localization of non-contrasting foreign bodies in the thoracic and diaphragmatic areas of the esophagus, the "symptom of the impression" is determined - the pendulum movements of the contrast suspension - the upward movement when swallowing a contrast fixed on the foreign body.

Diagnosis of foreign bodies in the stenosed esophagus helps: visualization of suprastenotic expansion of the esophagus with very weak peristalsis due to its atony: indications of previous operations, burns, trauma; correction of congenital atresia, sounding and repeated retention in the esophagus of foreign bodies. The basis for setting a preliminary diagnosis of cicatricial esophageal stenosis is a repeated delay in the esophagus of foreign bodies or objects that usually pass freely through the esophagus (small food pieces, small coins), as well as an indication in the history of esophageal injury. Large foreign bodies are accompanied by a food blockage above their localization, which has the appearance of a local expansion of prevertebral soft tissues, a horizontal liquid level with the air above it in the form of a triangle.

When diagnosing foreign bodies of the esophagus, such methods as swallowing bread crusts for revealing a pain reaction, a sample with a drink of water (the patient is offered to drink half a cup of water in a volley and in the absence of difficulty and pain make a conclusion about the absence of a foreign body) and x-ray examination using cotton wool, impregnated with a barium suspension (the so-called Frenkel test).

Laboratory research

Conventional clinical tests to clarify the severity of inflammatory events.

Instrumental research

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

When X-ray contrast is introduced into the esophagus, the results of X-ray diagnostics can be questionable, especially when small objects, fish bones, thin plastic plates are stuck. When staging an x-ray diagnosis, it should be borne in mind that the bulk (70-80%) of such items are stuck in the laryngopharynx and cervical esophagus. Larger foreign bodies are fixed in the middle parts of the esophagus.

For the detection of X-ray contrasting foreign bodies, various methods are used, depending on the level of foreign bodies. So, for the detection of foreign bodies in the cervical esophagus, reliable results are obtained by the method proposed by SI Ivanova (1932): the patient is offered to take 1-2 drops of barium sulfate suspension of medium density directly during fluoroscopy (preferably in the presence of an endoscopic physician) . Observation is led both by the act of swallowing, and by the movement along the esophagus of the contrast mixture. The study is carried out in I and II oblique projections. In the presence of foreign bodies, there is a complete or partial delay of the contrast agent, depending on the size, shape and location of foreign bodies, while the radiocontrast foreign body is enveloped by a contrasting substance and becomes visible. Subsequent throats of water easily wash away the contrasting mixture from the walls of the esophagus, while on the foreign body there remains some of it, allowing to determine the localization of foreign bodies. Thus, it is possible to detect more or less large foreign bodies with an uneven surface that retains the contrast agent, however, small and smooth linear objects, for example, needle fish bones, are usually not detected by this method. In these cases, it is recommended to perform radiography of the neck in a non-contrast way, the essence of which is that the X-ray tube is placed at a distance of 150 cm from the film (13x18 cm) located opposite the neck 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 produced at an anode voltage of 80-90 kV and a current of 50-60 mA with an exposure of 0.5-1 s with a delay in breathing. According to the author, this method can reveal the smallest fish bones and other low-contrast foreign bodies in the larynx, pharynx and cervical esophagus. The author points out that, in interpreting contrastless radiography, the age and sex characteristics of the larynx should be taken into account, so as not to take for foreign bodies laryngeal cartilage calcification sites, usually occurring after 40 years in men and later in women.

With blind gunshot wounds to the pharynx, larynx or cervical esophagus to determine the location of foreign bodies, V.Voyachek suggested inserting a "metal landmark" - a probe into the wound channel. When X-ray diagnosis of foreign bodies of the cervical esophagus, as well as firearms in the soft tissues of the neck, a number of factors should be taken into account, two of which are of the greatest importance: the imposition of the shadow of foreign bodies on the shade of the esophagus and the displacement of foreign bodies and, consequently, its shadows when turning the head. Taking into account these phenomena, KL Khilov (1951) proposed, in addition to the above oblique projections I and II, to make a third image with an X-ray contrast probe inserted into the wound channel in the position of the patient in which he will be in the course of surgical intervention . With the help of this technique, the localization of the foreign body in relation to the organs of the neck - pharynx, larynx, trachea, esophagus is specified. This method facilitates the use during the operation of induction probes, when introducing a sound signal into the wound and approaching the metallic foreign body. Modern video-surgical techniques in combination with intraoperative fluoroscopy and doppleroscopy allow to detect and remove a foreign body under the control of vision on the TV monitor screen.

To identify nonmetallic foreign bodies in the presence of a fistula or a wound channel connected with it, it is advisable to use the fistulography method, first proposed in 1897 by A. Graff, who used a 10% solution of iodine in glycerol as an X-ray contrast agent, a method for radiographic examination of fistulous passages. The main purpose of this method is to identify the direction, size and shape of the fistulous course, its branching and the establishment of connections and relationships with pathological foci-the abscess cavity, the focus of osteomyelitis, a sequester, foreign bodies complicated by the purulent process, and neighboring organs. As a contrast agent in fistulography, oil solutions of organic compounds of iodine or its water-soluble compounds (monocomponents - Trizograf, Omnipak, Ultravist-240, combined preparations - Urografine) are usually used. Before filling the fistula by one of these drugs, an overview radiograph of the area under investigation is made, at least in two projections.

After this, the edges of the fistulous opening are lubricated with 5-10% alcoholic iodine solution and the pathological contents contained in it are sucked from the fistulous course. The contrast agent is administered immediately before the examination in the X-ray room with the patient's horizontal position. The contrast agent is preheated to 37 ° C and injected into the fistulous course slowly, without effort, making sure that the syringe piston moves evenly without additional effort, which will indicate that the contrast agent enters only the pathological cavities without forming a false course. If a significant pain occurs during the administration of a 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 for 10 minutes are injected into the fistulous course, after which the rest of the anesthetic substance is aspirated and a contrast agent is injected. For hermetic sealing of the fistula syringe cannula (do not use the needle), it is necessary to put on it a special tip of SD Ternovski or increase its diameter by winding a strip of adhesive plaster. Having achieved a tight filling of the fistula, one should cover its hole with adhesive tape. If, at the time of tight filling of the fistula, a light introduction of a contrast agent suddenly appeared, this could mean either a breakthrough of the wall of the fistula with the penetration of the contrasting substance into the interstitial spaces, or that the contrasting substance reached the pathological cavity and began to penetrate it. In modern conditions, the fistulography method can be used for CT and MRI.

The method of radiography can diagnose such complications of the esophagus perforation, as pereezophagitis and phlegmon of the near-esophageal cellulose tissue.

After diagnostic fluoroscopy, which plays the role of an indicative means of diagnosing foreign bodies of the esophagus, they start esophagoscopy, which is simultaneously used to remove it when it detects foreign bodies. Therefore, when preparing for esophagoscopy, it is necessary to have the entire set of instruments available for carrying out this operation.

Esophagoscopy with foreign bodies of the esophagus is contraindicated only if there are reliable signs of perforation or rupture of the esophageal wall. When suspicion of the presence of foreign bodies esophagoscopy is conducted with great care by a doctor who has sufficient experience in the removal of foreign bodies of the esophagus. Young doctors, before proceeding with esophagoscopy, it is recommended to train this complex and responsible procedure on special models. When conducting esophagoscopy, four possible errors should be considered:

1. not the recognition of an existing foreign body;
2. erroneous "detection" of a foreign body, which is often taken as fragments of a damaged mucosa;
3. mistaken acceptance of the foreign body of the esophagus as a foreign body of the trachea; The reason for this error lies in the fact that a foreign body of considerable volume can squeeze the trachea and cause symptoms that are characteristic of the foreign body of the trachea (difficulty breathing);
4. not recognition of the esophageal perforation; This error can be avoided with a thorough clinical and radiological examination of the patient, which reveals subcutaneous and mediastinal emphysema.

Patients with suspected prolapse of a foreign body in the stomach are categorically prohibited from prescribing laxatives. Such patients are to be monitored in the hospital. To facilitate the progress of the foreign body through the digestive tract, a ration with a high content of plant fiber is recommended. The passage of metallic foreign bodies through the gastrointestinal tract is monitored by means of successively carried out at various times several survey radiological studies. It is also necessary to examine the excrement of the patient to make sure that the foreign body has come out.

Differential diagnostics

It conducts with congenital malformations of the esophagus and post-traumatic deformities of its lumen, neoplasms of the esophagus and neighboring organs.

Indications for consultation of other specialists

With the development of peri-oesophageal complications, in cases of difficult removal of foreign bodies in rigid endoscopy or fibroendoscopy, and even more so when it is necessary to remove the foreign body by the method of esophagotomy, consultation of the thoracic surgeon is necessary. In cases of severe complications, the nature and volume of detoxification therapy is coordinated with the reanimatologist

If the patient has conjugated diseases of internal organs and systems, after consulting a therapist and an anesthesiologist determine the type of anesthesia allowance.

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10],