Difficulty eating

Introduction It is a common symptom of esophageal disease, which refers to a symptom that food is hindered from oral to gastric delivery. Under normal circumstances, the food passes from the oral cavity to the stomach for about 6 to 60 seconds. If the food is found to be unable to reach the stomach smoothly, the residence time in the esophagus is prolonged, and the symptoms of obstruction are accompanied by the symptoms of dysphagia. Causes patients to eat difficult.

Cause

1. Oropharyngeal disease Oropharyngeal inflammation (viral, bacterial), oropharyngeal injury (mechanical, chemical), pharyngeal diphtheria, pharyngeal tuberculosis, pharyngeal tumor, posterior pharyngeal wall abscess.

2. Esophageal esophagitis (bacterial, fungal, chemical), benign esophageal tumors (leiomyomas, lipoma, hemangioma, etc.), esophageal cancer, esophageal foreign body, esophageal dysfunction (cardiac achalasia, diffuse Sexual esophageal fistula, etc.), extreme enlargement of the thyroid gland. Among them, esophageal cancer is an important cause.

3. Neuromuscular diseases, medullary paralysis, myasthenia gravis, organophosphate insecticide poisoning, polymyositis, dermatomyositis, pharyngeal achalasia and so on.

4. Systemic diseases Rabies, tetanus, botulism, iron deficiency dysphagia (Plummer-Vinson syndrome).

an examination

Related inspection

Esophagography, esophageal barium meal, gastroesophageal reflux, and imaging

1. Ask about medical history

(1) Age and gender: Children with dysphagia, often caused by congenital esophageal disease or esophageal foreign body; middle-aged patients with dysphagia symptoms gradually aggravated, should first consider esophageal cancer, more common in men; iron deficiency dysphagia The majority of patients are women, often with other clinical symptoms of iron deficiency anemia.

(2) medical history and incentives: esophagus with history of corrosive damage should consider esophagitis, benign stenosis; frequent reflux of gastric acid or bile is mostly reflux esophagitis (acidic or alkaline reflux); high incidence of esophageal cancer Patients should first consider esophageal cancer; dysphagia is caused by emotional agitation, suggesting that it may be caused by esophageal achalasia, primary esophageal fistula or neurosis (coloation).

(3) Obstruction site: The obstruction site shown by the patient is generally consistent with the anatomical site of the esophageal lesion, and has a reference significance for localization diagnosis. In the upper esophagus, dysphagia, in addition to cancer, can be caused by swollen thyroid, tuberculous or malignant granuloma, iron deficiency anemia of the pharynx, cervical esophageal fistula (congenital abnormalities) and other diseases; middle obstruction is often esophageal cancer Mediastinal lesions compress esophagus, benign esophageal stricture, esophageal polyps, esophageal submucosal tumors and other diseases; dysphagia in the lower esophagus is mainly caused by diseases such as cancer and esophageal achalasia.

(4) Relationship with eating: mechanical dysphagia may cause obstructive symptoms in solid food, soft food, and fluid as the degree of obstruction of the lumen is aggravated; exercise dysphagia such as esophageal achalasia, esophageal fistula patients eating solid Or dysphagia in the liquid food; pharyngeal muscle paralysis caused by cerebral neuropathy, exercise incoordination can be expressed as drinking water ruminant (water sputum into the trachea).

(5) Accompanying symptoms:

1 dysphagia with hiccups often suggest lower esophageal lesions such as cardia cancer, achalasia, convulsions and so on.

2 with hematemesis seen in esophageal cancer, granulomatous lesions, reflux esophagitis or ulcers.

3 with swallowing pain is more common in oropharyngeal inflammation or ulcers, esophageal inflammation or ulcers, esophageal achalasia and so on.

4 with unilateral wheezing often suggest that mediastinal tumor compression of the esophagus or compression of the main bronchus may be.

2. Signs: physical examination should pay attention to the patient's nutritional status, with or without anemia, superficial lymphadenopathy, goiter, neck mass, abnormal swallowing muscle activity, etc., if necessary, for neurological examination to identify swallowing-related There are abnormalities in the cranial nerves (IX, X, XII on the cranial nerves) and the swallowing muscles.

Laboratory inspection:

1. Drinking water test patients take a sitting position, place the stethoscope between the patient's xiphoid and the left rib arch, sip a drink, normal people can hear jet murmur after 8 ~ 10s, if there is esophageal obstruction or dyskinesia, then listen No sound or delay, even severe obstruction can even vomit water. This method is simple and easy, and can be used as a method for initially identifying the presence or absence of obstruction of the esophagus.

2. Esophageal acid test is important for the diagnosis of esophagitis or esophageal ulcer. The patient took a sitting position and was introduced into the nasogastric tube to be fixed 30 cm away from the outer nostril. The saline was first instilled, 10 to 12 ml per minute. After 15 minutes, 0.1 N hydrochloric acid was instilled at the same rate. The patient with esophagitis or ulcer was generally within 15 minutes. Pain or discomfort after burning the sternum, and then with saline infusion, the pain gradually relieved.

3. Esophageal 24-hour pH monitoring 24-hour pH monitoring in the esophageal lumen is important for the diagnosis of acidic or alkaline reflux.

4. Conduct an examination of immunology and tumor markers.

Other auxiliary inspections:

1. X-ray examination: X-ray chest radiograph can understand whether there is any foreign body in the mediastinum or esophagus with or without space-occupying lesions; esophageal X-ray barium meal examination can observe the presence or absence of tincture to determine the lesion as obstructive or muscle Creeping disorder. If necessary, use gas sputum double contrast to understand the changes of esophageal mucosal folds. Endoscopy and biopsy can directly observe esophageal lesions, such as esophageal mucosal congestion, edema, erosion, ulcers or polyps, cancer, etc.; can observe the presence or absence of stenosis or local expansion of the esophagus, with or without achalasia. Endoscopic biopsy is important for the differentiation of esophageal ulcers, benign tumors and esophageal cancer.

2. Esophageal manometry: Esophageal manometry can be used to determine the functional state of the esophagus, generally using a catheter side hole low pressure irrigation manometry. The normal esophageal sphincter (LES) base pressure is 12-20 mmHg, LES pressure/intragastric pressure>1.0, such as pressure 10 mmHg, LES pressure/intragastric pressure <0.8, suggesting gastroesophageal reflux. However, it has been found that the LES pressure of the gastroesophageal refluxer overlaps with the normal person. After that, the pressure is measured by the catheter extraction method, and the LES pressure value at the end of the expiratory phase is taken as the standard. In patients with esophageal achalasia, only non-creeping small contraction waves were observed, and there was no obvious peristaltic contraction wave after swallowing action; while esophageal fistula patients could detect strong esophageal contraction waves, and LES relaxation function was good.

Differential diagnosis

1. Esophageal cancer: Esophageal cancer is more common in male patients over 40 years old. The typical symptoms are progressive dysphagia. Most patients can clearly indicate that the obstruction site is behind the sternum and may be accompanied by swallowing pain. Late patients may have esophageal reflux. Often mucus or mixed food or food every other day, when the food can not pass through the cardia, the vomit is not acidic; X-ray swallowing can be seen in the esophageal local mucosa thickening or interruption, irregular stenosis, sometimes see a small shadow; Esophageal exfoliative cytology is important for early diagnosis. Esophagoscopy or endoscopy combined with biopsy can determine the diagnosis of esophageal cancer.

2. Esophageal achalasia: due to weakening or disappearance of esophageal peristaltic waves, LES loss, so that food can not pass through the cardia. Most of the dysphagia is intermittent, the course of disease is longer, the lower part of the esophagus (ie above the stenosis) is obviously dilated, the esophageal reflux is common, the reflux is large, and the bloody mucus is not included, especially in the supine at night, it can be awakened by cough and even Causes aspiration pneumonia. Patients often had no significant progressive wasting symptoms. X-ray swallowing examination showed that the cardia obstruction was fusiform or funnel-shaped, with smooth edges. After inhalation of isoamyl nitrite, the cardia could be dilated temporarily, allowing the expectorant to pass; the esophageal manometry was only non-existent. Peristaltic small contraction wave; esophagoscopy or gastroscope to see the lower part of the esophagus mucosa is normal, no new organisms in the esophageal lumen, sometimes endoscopy can not pass the stenosis, mucosal biopsy without cancer cells.

3. Gastric-esophageal reflux: dysfunction of the lower esophageal sphincter, loss of function of the anti-gastroesophageal reflux barrier, and the contents of the stomach and duodenum often flow back into the esophagus, eventually leading to chronic inflammation of the esophageal mucosa and even ulceration. Mainly manifested as burning sensation or pain in the back of the sternum, accompanied by difficulty swallowing, caused by acid, cold, overheated food-induced esophageal spasm. In the later stage, benign esophageal stenosis, LES pressure measurement in the lower esophagus, 24-hour pH monitoring in the esophagus, and Bilitee-2000 bile monitor to measure the bilirubin absorption value are helpful for the diagnosis of acid and alkali reflux. In patients with significant lesions, the mucosa showed inflammation, erosion, or ulceration during esophagoscopy or gastroscopy. In the early stage of reflux or mild lesions, erosion or ulceration may not be obvious.

4. Benign stricture of the esophagus: stenosis is caused by corrosive factors, esophageal surgery, injury, reflux esophagitis. Dysphagia caused by scar stenosis has a long course of disease and can be progressively aggravated, often accompanied by antifeeding. X-ray swallowing examination showed that the lumen was narrow, but the edges were neat, and there were no signs of stenosis, and esophagoscopy or gastroscopy could confirm the diagnosis.

5. Diffuse esophageal fistula: multiple secondary to reflux esophagitis, corrosive esophagitis and other diseases, often confused with angina pectoris, and the cause of primary diffuse esophageal fistula is unknown, can be seen at any age without esophagus The basis of inflammation. The main symptoms are dysphagia and swallowing pain, which are mostly caused by mental factors such as emotional agitation. Swallowing pain can be located in the front chest, even to the forearm, and nitroglycerin can often relieve pain.

6. Others: esophageal fistula, mediastinal tumor, enlarged lymph nodes around the esophagus, enlarged left atrium, aortic aneurysm, etc., such as compression of the esophagus can lead to difficulty swallowing. However, according to the symptoms, signs, X-ray, CT, MRI and other auxiliary examinations can be diagnosed separately, these lesions in the esophageal swallow examination, can be seen in the esophageal cavity pressure changes.

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