Symptoms of foreign bodies of the esophagus

Clinical symptoms are very diverse - from asymptomatic carrier to severe condition, depending on the species, the level of fixation and the time spent in the esophagus of the foreign body, and on the nature of the complications that developed. The most pronounced disturbances are caused by foreign bodies of the neck part of the esophagus. This is the forced position of the head with a forward and downward inclination; refusal to eat; sharp pain when swallowing in the area of the jugular tenderloin; hypersalivation; saliva retention in pear-shaped sinuses (Jackson's symptom); congestion in the throat of frothy mucus and difficulty swallowing solid foods; multiple, not bringing relief vomiting; slow speech; soreness in palpation in the supragastral region and in the displacement of the soft tissues of the neck; an admixture of blood in the saliva and vomit in the case of pointed foreign bodies. Large foreign bodies of the first fenziologic narrowing of the esophagus are accompanied by symptoms of respiratory failure, and a prolonged stay of a foreign body in the cervical esophagus in infants leads to the development of bronchopulmonary pathology.

The signs of a foreign body getting stuck in the esophagus depend on its shape and size, and also on the level of the wedge. Foreign bodies with a smooth surface, but of considerable magnitude, do not cause severe acute pains, but are accompanied by a sensation of raspiraniya in the chest and dull pain. Sharp foreign bodies that have wedged into the esophageal wall, wounding it, cause acute unbearable pain, which is aggravated by movements in that part of the neck or trunk at the level of which the wedge occurred.

All the symptoms of foreign bodies of the esophagus are divided into immediate, early and late. The first are due to a primary reaction to the introduction or wedging of foreign bodies and its mechanical influence on the esophagus wall, the latter manifest themselves following the primary reaction and progress during the subsequent acute clinical period; the third ones are detected in case of complications (perforation, infection). Pain sensations and other signs provoked by them are defined as a pain syndrome with foreign bodies of the esophagus, which evolves along with the development of the entire clinical picture of foreign bodies of the esophagus.

Immediate symptoms, as already noted above, are manifested in the appearance of a sensation of pain that arose during the swallowing of foreign bodies, rapidly increasing and accompanied by drooling. These pains, depending on their nature and intensity, may indicate the stucking of foreign bodies, damage to the mucous membrane, perforation of the esophagus wall or its rupture. Sometimes there is also aphonia caused by repercussion (reflex).

Early Symptoms

Early symptoms are characterized by the establishment of qualitative signs of pain syndrome. So, the intensity of pain can be indicative of the level of introduction of foreign bodies in this period: the upper sections of the esophagus are more sensitive, the lower ones are less sensitive to pain stimuli, therefore the most pronounced pain syndrome occurs when foreign bodies are incised into the upper esophagus. Pain can be permanent or variable in nature. The constant pain testifies to the introduction of foreign bodies into the wall of the esophagus with its damage or even perforation. Variable pain in most cases indicates only the incidence of foreign bodies in the lumen of the esophagus and is strengthened only when moving in the cervical spine and thoracic spine. Painful sensations can be localized (in the neck, behind the breastbone or in the interstitial space), spilled, irradiating. In children, pain can be absent, as well as in adults, especially with smooth-walled round foreign bodies. If foreign bodies are implanted in the tracheal bifurcation region, the pain is localized retrosternally in the depth of the chest cavity or prevertebrally at the level of II - IV thoracic vertebrae. The introduction of foreign bodies into the lower parts of the esophagus causes a feeling of pressure in the depth of the chest and pain in the heart and in the epigastric region. Sometimes the pain radiates to the back, waist and sacral region. Often complaints of a patient with pain of different locations are due only to trace phenomena left by foreign bodies on the esophagus wall (most often abrasions or even deeper lesions), while the foreign body itself slipped into the stomach.

Along with pain, dysphagia occurs, which is especially pronounced for solid foods and can be mild or absent when taking liquid food or water. Absence of dysphagia does not exclude the presence of foreign bodies. Dysphagia in the presence of foreign bodies is almost always accompanied by vomiting or regurgitation. In the period of early symptoms, especially when it is impossible to drink, the thirst develops in the affected people, they begin to lose weight not only because of the lack of water in the body, but also because of nutritional deficiencies.

If the foreign body is in the upper part of the esophagus, then its volume can move the larynx anteriorly, causing the lower part of the pharynx to appear wider (Denmeyer's symptom). The pressure on the larynx in front for a given localization of foreign bodies causes the appearance or intensification of pain (Schlittler's symptom). The accumulation of saliva and mucus in pear-shaped fossa (Jackson's symptom) indicates complete or partial obstruction of the esophagus, which is observed not only in the presence of foreign bodies, but also in tumors or burn it.

Disturbances of respiration arise if the foreign body is stuck at the entrance to the esophagus or at the level of the larynx. These disorders can be caused by the mechanical or reflex influence of foreign bodies, leading to compression of the larynx and its spasm. Sometimes these breathing disorders are so great that you have to make an emergency tracheotomy. Disturbances of respiration can be caused by compression of the trachea when foreign bodies are bent before bifurcation. If, nevertheless, when the foreign bodies are less than the bifurcation, the dyspnea is present, it is due to the emerging inflammatory edema of the fiber surrounding the trachea or one of the main bronchi. Especially severe forms of breathing disorders occur with inflammatory edema in the area of the entrance to the larynx with the involvement of an arytenoid cartilage and cherpalodnagloth folds in this process. The compression of the larynx and trachea can be accompanied by a noisy (hissing, wheezing, stridorous) breathing, an indomitable cough. Since dyspnea depends on the position of the head when the foreign bodies are rubbed at the level of the larynx, the patient gives it a forced position, more often it is tilted forward and somewhat to the side. When foreign bodies are incised in the thoracic spine, the patient assumes the forced position of the torso forward, in which the pain is somewhat reduced due to a decrease in the tension of the esophagus.

At the end of the period of early symptoms, a triad of symptoms may arise, described by Killian (Killian triad):

1. a sharp increase in pain and their distribution below the level at which they were noted at the time of foreign bodies' wedging;
2. infiltration in the soft tissues of the neck and in the region of the cricoid cartilage;
3. a sharp increase in the temperature of heat with chill.

This triad indicates the spread of the inflammatory process to the surrounding esophagus of the cellulose. Secondary symptoms can arise immediately after primary, but sometimes they appear after some "light" period, which can last for more than one day. In this period, dysphagia can be minimal and manifest only when taking dense food or not at all.

[1], [2], [3], [4], [5], [6]

Late symptoms

Late symptoms follow the period of early symptoms and are manifested first by signs of local, then diffuse inflammation of the esophagus and near-esophageal cellulose. In the perforation of the esophagus, the signs of this inflammation tend to occur simultaneously with early symptoms.

Perforations of the esophagus can be primary and secondary. The first arise much less often than the perforations caused by unsuccessful manipulations when removing foreign bodies or pushing it blindly into the stomach. The latter arise from the formation of decubitus and ulceration of the esophagus wall, followed by a submucosal abscess, melting of the muscular layer and penetration of the acute part of the foreign body into the circumsophageal space.

Developing cervical or thoracic mediastinitis leads to a sharp deterioration in the general condition of the patient, the appearance of chills and high body temperature; Dysphagia becomes complete, pain - spontaneous and unbearable; signs of sepsis are established.

Signs of perforation are characterized by some particular features that depend on the level of damage to the esophagus.

Perforations at the level of the cervical esophagus in fresh cases initially differ in benign course. However, they are complicated early by an abscess in the region of the near-esophageal cellulose with its spread outwards or into the esophagus. In the first case, this process is manifested by the appearance in the region of the carotid triangle of swelling, smoothing relief in this region. Movement in the neck becomes very sensitive and painful. The larynx moves to a healthy side. The pathognomonic symptom of esophageal perforation in the cervical region is subcutaneous emphysema on the neck on the side of the perforation, which occurs when the air is swallowed (empty mouthful) and spreads to the face and front surface of the chest. To the atmospheric air, gases produced by anaerobic microorganisms can be added.

In the second case, the perforation of the esophageal wall leads to a rapid development of the phlegmon of the neck, which propagates unobstructedly down to the posterior mediastinum. Pus from behind-esophageal space can also descend along the neurovascular bundle into the supragastral space and anterior mediastinum. Of the clinical symptoms with a significant spread of the process very early, there is a breathing disorder. Purulent processes in the spaces between the esophagus, trachea and the pre-invertebral fascia most often come from the behind-the-mouth lymph nodes, where the infection enters the infected foreign bodies of the upper esophagus. These processes cause a severe clinical picture mainly due to a breathing disorder and swallowing.

Without timely surgical intervention, which in overwhelming majority of cases against a background of massive antibiotic therapy predetermines a favorable outcome, the purulent-inflammatory process quickly evolves with expansion into the mediastinum, the breakdown of pus in which causes a temporary improvement in the patient's state (lowering of body temperature, reduction of pain intensity, disappearance of swelling in neck area). This false "recovery" is a formidable sign of future mediastinitis, whose prognosis is extremely serious.

Perforations at the level of the thoracic esophagus are initially characterized by a poor clinical course characterized by early development of symptoms of acute purulent mediastinitis. If the infection develops immediately after perforating the esophagus, the mediastinitis acquires the character of a diffuse phlegmon with the development of sepsis. The prognosis at this stage of the development of the inflammatory process, if not hopeless, is very serious. Between the period of primary signs of perforation and diffuse mediastinitis may be a short period of limited mediastinitis, an operative intervention in which can save the life of the patient.

Perforations at the level of the abdominal part of the esophagus show signs of an "acute" abdomen with the development of peritonitis. This type of complication also requires urgent surgical intervention.

When fixing a foreign body in the thoracic part of the esophagus, the symptoms are less pronounced. The sternum pain is characteristic, increasing at attempts of a swallowing and irradiating in mezhlopatochnuju area and an arm or a hand; the urge to vomit is less frequent: salivation is less pronounced, as there is a possibility for its accumulation in the upper third of the esophagus.

Foreign bodies of the diaphragmatic part of the esophagus cause shingles in the epigastric region. Salivation is uncharacteristic. When trying to swallow solid food, vomiting occurs. With partial obturation of the lumen of the esophagus, liquid food can pass into the stomach.

Clinical symptoms are most pronounced in the first 24 hours after ingestion of a foreign body. On the second day, the pain is weakened as a result of a decrease in the reflex spasm of the esophagus. Patients try to avoid rough food, create a false impression of well-being. After 2 days the condition deteriorates sharply due to the development of esophagitis and pereezophageal complications.

In infants and young children, clinical symptoms are atypical. The initial symptoms quickly pass, and the emerging stenotic phenomena are regarded as manifestations of acute respiratory disease. Foreign bodies in newborns cause the child's anxiety and the urge to vomit during feeding, salivation, respiratory failure, early development of aspiration pneumonia and inflammatory changes in the esophagus wall and peristal esophagus with hyperthermia, toxicosis, exsicosis, parenteral dyspepsia.

Complications

Complications develop in 10-17% of cases of origin of foreign bodies of the esophagus, especially often in childhood. The smaller the age of the child, the more likely the development of complications, the sooner they appear and the more severe they are.

Esophagitis is diagnosed within a few hours after ingestion of a foreign body, it is catarrhal, purulent, erosive-fibrinous (this form is accompanied by painfulness when turning the head and palpating the neck, nausea, vomiting with blood impurities, forced head position, temperature reaction). There are unpleasant sensations behind the sternum, a moderate soreness in swallowing, a slight salivation. When the endoscopy is in place of localization of a foreign body, an eroded surface with dirty-gray necrosis areas and excess granulation growth is detected. When fluoroscopy is determined "air bubble symptom" and "air arrow symptom" in the lumen of the esophagus at the level of mucosal injury.

The development of pereezophagitis is accompanied by a worsening of the general condition, increased pain behind the sternum, an increase in body temperature, the appearance of soft tissue edema and subcutaneous neck emphysema, a significant increase in the tone of the neck muscles, forced head position, submaxillary, zagrugal and cervical lymphadenitis. Possible development of respiratory stenotic disorders due to jet edema of the outer ring and podgotosovoy cavity of the larynx, pneumonia. When fluoroscopy is determined by the increasing expansion of the post tracheal space with air bubbles in the near-esophageal cellulose, straightening the physiological lordosis, pushing the air column of the larynx and the trachea forward is a symptom of the soft tissues of Stuss; rectification of the cervical esophagus due to severe soreness - a symptom of GM. Zemtsova.

In the abscess of the perisophageal tissue, the horizontal level of the fluid and the multiple air bubbles in the periesphageal tissues are seen.

Mediastinitis often develops with penetrating and large injected foreign bodies due to perforation and development of pressure ulcers of the esophageal wall. There are symptoms of purulent intoxication, the condition worsens sharply, hyperthermia is noted. Pain increases and descends lower as a result of descending mediastinitis. Characteristic is the forced position of the body (semi-sitting or on its side lying) with the legs brought to the abdomen. Breathing is difficult, groans. The sharp pallor of the skin, when talking and deep breathing, pain intensifies. The most severe is mediastinitis with perforation of the lower third of the thoracic esophagus.

Among other complications of foreign bodies of the esophagus, phlegmonous pereezophagitis with necrosis, gangrene of esophageal wall, pleurisy, pneumothorax, lung abscess, sepsis, fibrinous-purulent pericarditis, peritraheal abscess with pus penetration into adjacent tissues, lesion of lower laryngeal nerve, IX-XII cranial nerves and the danger of an erosive bleeding from large vessels, mediastinum.

[7], [8], [9], [10], [11]