Pendulum sign

Introduction In a small number of cases of stenosis of the esophagus, a small sac-like area (which is a normal esophagus) is also seen between the stenosis and the cardia. It is called a "pendulum" and is called a "pendulum sign." This symptom is also common in cases of congenital esophageal stricture (CES), duodenal hoarding, and a small number of esophageal ectopic tissues. Congenital esophageal stenosis is the result of excessive proliferation of mesophyll components in the trachea, esophageal septum or esophageal sac in the development of esophageal embryos, and occurs mostly in the position below the tracheal bifurcation. Congenital esophageal septum is quite rare. Most of the esophageal lumen is blocked by a film or fiber band, leaving only small holes that can pass through the liquid food.

Cause

This symptom is also common in cases of congenital esophageal stricture (CES), duodenal hoarding, and a small number of esophageal ectopic tissues.

Congenital esophageal stenosis is the result of excessive proliferation of mesophyll components in the trachea, esophageal septum or esophageal sac in the development of esophageal embryos, and occurs mostly in the position below the tracheal bifurcation. Congenital esophageal septum is quite rare. Most of the esophageal lumen is blocked by a film or fiber band, leaving only small holes that can pass through the liquid food. It may not present clinical symptoms during infancy and may cause difficulty swallowing when eating thick paste or solid food. Esophageal X-ray angiography showed localized stenosis of the esophagus. Esophagoscopy can be used to see the lesion and confirm the diagnosis. The membrane-like septum can be cured by esophageal mirror expansion. For the toughness of the diaphragm, a thoracotomy should be performed to remove the narrow esophagus at the site where the diaphragm is located, and then the esophagus can be anastomosis.

In embryonic development, in the vacuole stage of esophageal formation, excess mucous membranes are absorbed, and vacuoles disappear, but some or complete esophageal mucosal annular septum remains. In addition, it is thought to be caused by excessive growth of the squamous epithelium in the process of esophageal development. According to the pathological features of congenital esophageal stricture, Nihoul-Fekete (1987) divided it into 3 types:

1. Membrane sputum or hernia formation: also known as membrane-like stenosis, is the most rare type, it is considered to be a confused form of esophageal atresia, often occurs in the middle or lower part of the esophagus. The surface of the membrane or tendon structure is covered with squamous epithelium, and the typical onset of symptoms is just when eating is heavily weighted into solid food.

2. Fibromuscular hypertrophy: also known as idiopathic muscular hypertrophy or fibromuscular stenosis, is the most common type of congenital esophageal stricture. Histological features are submucosal smooth muscle fibers and fibrous connective tissue hyperplasia with normal squamous epithelial coverage, similar to pyloric hypertrophic stenosis, but no clear embryonic and pathogenic factors to explain the lesion.

3. Remnant trachea and bronchial tissue in the esophageal wall: also known as tracheal primordial stenosis, and its tracheal and bronchial residuals may be part of the anterior intestine malformation pleats. In 1936, Frey and Duschel first reported that a 19-year-old woman was found to have died of achalasia. Since then, Holder et al. (1964) specifically focused on 1058 cases of esophageal atresia in the esophageal atresia. In 1973, Spitz confirmed that the disease is based on congenital lesions. Since 1991, nearly 50 cases of congenital esophageal stenosis caused by residual esophageal bronchial tissue have been reported in English and German literature.

Congenital esophageal stenosis occurs in the upper or lower segment of the esophagus. It is reported that about 50% occur in the 1/3 segment of the esophagus, and 25% occur in the lower third segment of the esophagus. Fibromuscular hypertrophy and stenosis is more common in the esophagus or lower esophagus in the thoracic cavity, while the residual trachea and bronchial tissue in the esophageal wall are seen in the lower part of the esophagus.

an examination

Related inspection

Esophageal pressure measurement esophagography gastric sputum meal angiography duodenal barium meal angiography

Children repeatedly have food reflux or cough after meal, and older children have a post-meal wheezing performance, which should be highly suspected. X-ray esophageal barium meal and esophagoscopy showed esophageal stricture or membranous fistula, which can be diagnosed. Laboratory examination: 24 hours of esophageal pH monitoring is feasible, and if necessary, the esophageal mucosal living tissue is taken for pathological examination to aid diagnosis.

Other auxiliary inspections:

1. Esophageal barium meal angiography: According to the imaging characteristics of barium meal angiography, esophageal stenosis can be divided into two types.

(1) Long-segment type: stenosis occurs in the lower part of the esophagus and is about several centimeters long. The narrow edge is not smooth, the esophagus is dilated above the narrow segment, and the expectorant is slow, showing reverse creep. This type of clinical symptoms appear earlier, similar to reflux esophagitis, X-ray is difficult to identify.

(2) short segment type: often occurs in the middle and lower part of the esophagus, the narrow segment is about several millimeters to 1 cm long, the edge is smooth, and the mucosa is regular. The esophagus was slightly dilated above the stenosis, the expectorant was down, and the distal esophagus was normal. Sometimes foreign matter or food blocks are likely to persist on the stenosis. The narrow segment cannot expand. This disease is often associated with aspiration pneumonia, routine chest X-ray examination.

2. Esophagoscopy: Pediatric microscopy provides a primary objective basis for the nature of the stenosis.

3. Esophageal pressure measurement.

Congenital esophageal stricture in children is rare in clinical practice. It is generally divided into muscular hypertrophy (FMS), tracheal cartilage ectopic (TBR), and sputum (MD) type 3. All patients were treated with progressive dysphagia and vomiting. All patients underwent barium meal and 83.3% were diagnosed by esophagoscopy. In the middle section of the TBR, X-ray examination has a typical "pendulum sign" and achalasia easily identified; the lower part of the TBR "rat tail sign" and the cardia achalasia is more rigid than the "radish root" X-ray signs are difficult to identify, X-ray barium meal found that esophageal hiatal hernia and 24 h pH monitoring were helpful to identify the stenosis caused by FMS and esophageal hiatus hernia.

Complications: Reflux food and saliva can enter the trachea, causing inhaled bronchitis or pneumonia due to food reflux after feeding or eating.

Differential diagnosis

Differential diagnosis of the pendulum sign:

1. Cardiac achalasia: The stenosis is located in the cardia, which is intermittently open, and the expectorant can be sprayed into the stomach. Congenital esophageal stricture is a persistent stenosis with no open jet signs, but the expectorant can continue to pass. Usually the esophageal dilatation above the stenosis is not as obvious as the achalasia.

2. Acquired reflux esophagitis: the esophageal stenosis is not smooth, uneven, mucosal destruction or sputum, sometimes visible esophageal hiatus hernia. In the follow-up observation, the degree of stenosis can be aggravated and lengthened. Clinical symptoms are also aggravated.

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