Chest pain after eating

Introduction Chest pain after eating is a major manifestation of spontaneous esophageal rupture. Spontaneous Rupture of Esophagus refers to a sudden increase in pressure in the esophageal lumen caused by various reasons, resulting in a longitudinal tear of the entire left side wall of the esophagus on the adjacent diaphragm. Also known as Boerhaave syndrome, spontaneous esophageal tear syndrome, esophageal pressure rupture, esophageal digestive perforation, non-traumatic esophageal perforation. Most occur after drinking and vomiting.

Cause

(1) Causes of the disease

Although not 100% of patients have vomiting at the time of onset, most patients (70% to 80%) have vomiting followed by esophageal perforation, so vomiting remains the most important cause. Associated with vomiting is drinking, and most of the patients who vomit are vomiting after overeating and drinking. Other causes of spontaneous esophageal rupture include childbirth, car accidents, post-cranial surgery, and epilepsy. Spontaneous esophageal rupture is caused by increased abdominal pressure conduction to the esophagus, which can be formed at the distal end of the esophagus, and the cleft is more common in the lower esophagus. Because the upper segment is mainly skeletal muscle, it is not easy to rupture, while the middle and lower segments are mainly smooth muscle. The longitudinal muscle fibers are gradually reduced, the muscle layer is thin, and the vascular nerve is less, which is easy to rupture. The crevices are mostly longitudinal, 4 to 7 cm long, near the level of the lower pulmonary veins.

The stress factor that causes spontaneous esophageal rupture is not the absolute pressure in the stomach, but the pressure difference across the transmural junction of the gastroesophageal junction. After the perforation of the esophagus, if there is no communication with the pleural cavity (the mediastinal pleura is not broken), the strong acidic gastric juice, the stomach contents, and the swallowed oral saliva containing a large amount of bacteria, under the action of the pleural cavity negative pressure, overflow through the perforation The mediastinum mainly causes mediastinal infection and digestive juice to corrode the tissue, but in the later stage, the infected substance can also penetrate the mediastinal pleura into the pleural cavity, causing chest infection. If the mediastinal pleura is ruptured at the same time after perforation of the esophagus, the chest infection is the main manifestation.

(two) pathogenesis

Under normal circumstances, when vomiting occurs, the intragastric pressure suddenly increases, and the esophagus is reflexively relaxed to discharge the stomach contents. If the vomiting action occurs with ataxia, the upper esophageal sphincter can not relax or a certain contraction of the esophagus, the contents of the stomach can not be discharged, and the pressure in the esophagus increases sharply, resulting in the full-layer rupture of the esophageal wall with weak local resistance. Spontaneous esophageal injuries in adults do not occur frequently. Once it occurs, it involves the thoracic and abdominal esophagus, and spontaneous perforation of the cervical esophagus is rare. Spontaneous esophageal injuries fall into three categories: 1 interstitial hematoma (incomplete perforation); 2 mucosal tears (Mallory Weiss syndrome); 3 complete rupture (Boerhaave syndrome). Increased intra-abdominal or esophageal pressure in adults can cause esophageal damage. Esophageal rupture can occur in weight-lifting, fecal exertion, or abdominal ablation. Severe vomiting, esophageal fistula or foreign body, including food mass obstruction of the esophagus, causing a sudden increase in intra-abdominal pressure, can occur perforation.

Spontaneous esophageal rupture can also occur in newborns, which is rare. Acute dyspnea within 48 hours after birth should exclude spontaneous esophageal rupture of the esophagus. Esophageal rupture often involves the full thickness of the esophagus, and most cases extend to the right thoracic cavity. The exact mechanism is unknown. There may be a blockage at the upper end of the esophagus, resulting in increased pressure in the esophagus. The pressure during childbirth is transmitted to the esophagus filled with amniotic fluid. When the glottis and pharynx are closed, the pressure in the esophageal lumen is increased. In the regurgitation and vomiting, the circumflex pharyngeal muscle and the upper esophageal muscle layer are not coordinated or the esophageal hypertension may occur after birth, resulting in perforation of the esophagus.

an examination

Related inspection

Esophagography chest CT examination chest MRI

According to the medical history and clinical symptoms, the corresponding examination is carried out to provide the basis for the next diagnosis and treatment:

(1) Age: Most of the 50-60 years old middle-aged, infants and young people are less common, males are significantly more than females, about 1:5.

(2) Medical history: It is very important to ask about the medical history in detail. Anyone who suddenly has chest pain or severe pain in the upper abdomen after drinking or eating a lot of food should be suspected of having the disease. Barrett's triple sign: shortness of breath, abdominal tenderness, and subcutaneous emphysema in the neck are important for diagnosis.

(3) X-ray examination: It is the most important inspection method, not only can determine the presence or absence of perforation, but also can locate the perforation.

Symptoms and signs:

(1) The initial symptoms are vomiting, nausea, upper abdominal pain, and chest pain. One third to one-half of the patients have hematemesis. Patients with vomiting often have a history of drinking or overeating. Most of the pain is in the upper abdomen, but also in the back of the sternum, the ribs in the two seasons, the lower chest, and sometimes the shoulders and back. When the symptoms are severe, there may be shortness of breath, difficulty breathing, cyanosis, shock, etc.

(2) physical examination is often manifested as acute abdomen, may have the corresponding signs of liquid pneumothorax, upper abdominal tenderness, muscle tension, and even slab. Esophageal and gastric contents entering the chest and peritoneal cavity can cause chemical chest and peritonitis, and can have acute suppurative mediastinal inflammation and chest and peritonitis. The main clinical manifestations of spontaneous esophageal rupture are chest pain and upper gastrointestinal bleeding. The different types of performance are as follows:

Perforation of the esophageal wall

Clinically more common in older women, often followed by severe pain in the posterior sternal and posterior sternal and upper abdomen, and quickly radiated to the back, with a small amount of hematemesis and hypothermia, no mediastinal emphysema and subcutaneous emphysema.

2.MalloryWeiss syndrome

Adult males aged 40 to 60 years old. Most patients have binge drinking or long-term drinking habits, and can also occur as a result of regular aspirin. The patient complained of hematemesis after a large amount of vomiting and retching, often containing blood, and there were also cases of melena. Only a small percentage of patients have chest pain.

3. Boerhaaave syndrome

Also more common in middle-aged men. A typical medical history is severe nausea and vomiting after a large diet. The lower esophagus perforation has severe lower chest and xiphoid pain, and may have radiation pain in the back and shoulders. Some patients have only upper abdominal pain, accompanied by shortness of breath, difficulty breathing or shock. Hypotension, heart rate and respiratory rate may increase. The gas overflows through the rupture of the esophagus to form mediastinal emphysema, which in turn causes subcutaneous emphysema on the sternum and chest wall. Auscultation can be heard pleural or pleural pericardial friction, a sign of pleural effusion or liquid pneumothorax. There are signs of tenderness in the upper abdomen and a decrease or disappearance of bowel sounds.

Differential diagnosis

Differential diagnosis of chest pain after eating:

1. Chest pain during swallowing: Chest pain caused by esophagitis, hiatal hernia, diffuse esophageal fistula, and esophageal tumor often occurs or worsens when swallowed.

2, cardiogenic chest pain: mentioning cardiogenic chest pain, people often think of middle-aged and elderly people suffering from coronary heart disease angina, or even myocardial infarction. In fact, cardiogenic chest pain is not caused by coronary heart disease. At present, with the acceleration of people's life and work pace, many teenagers often have heart-induced chest pain.

3, smoking chest pain: 20 to 30 years old thin high-male male is the main predileous group of spontaneous pneumothorax, most patients have family tendencies and smoking habits. According to statistics, the rate of diarrhea among smokers is nine to eleven times higher than that of non-smokers. Patients have chest pain, chest tightness, and shortness of breath, and the majority of chest pain is manifested. Due to the young, tall and thin reasons, patients often do not care, ignoring the importance of medical examination.

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