Dysphagia - difficulty swallowing, is a symptom of diseases of the upper gastrointestinal tract and nervous system. Dysphagia, even episodic, and especially often recurring, and even more so permanent, requires a visit to a doctor and a thorough diagnosis, since the diseases in which it manifests itself are very serious.

Depending on the cause that caused it, dysphagia can be:

• true;
• Functional, when there are no mechanical obstacles to the process of swallowing, but there are only disorders of the nervous system;
• Caused by organic lesions, when there are diseases of the upper gastrointestinal tract or neighboring organs that prevent the passage of the food bolus.

The most common cause of dysphagia is precisely diseases of the esophagus, which create mechanical obstacles to the advancement of the food bolus. This condition is called esophageal dysphagia. The causes of esophageal dysphagia are as follows: esophageal ulcer, esophagitis (inflammation of the esophageal mucosa), esophageal stricture - cicatricial post-traumatic narrowing of the esophagus, tumor of the esophagus.

In addition, the cause of dysphagia can be diseases of the organs adjacent to the esophagus, in which its compression occurs. For example, hernia of the esophageal part of the diaphragm, nodular goiter, aortic aneurysm, mediastinal tumor, etc.

True dysphagia, a violation of swallowing itself, that is, the movement of a food bolus from the oral cavity into the pharynx, occurs when the nerve centers that control the act of swallowing are damaged, as a result of which this well-coordinated process is unbalanced, and the contents of the food bolus, when trying to swallow it, do not fall into the esophagus, but into the respiratory tract - nasopharynx, larynx, trachea. As a result, a spasm of the airways occurs, up to suffocation, a strong reflex cough occurs.

Functional dysphagia occurs with functional disorders of the nervous system - increased excitability, neuroses, etc. In this case, the symptoms of dysphagia appear episodically, as a rule, they are provoked by one or more types of food (solid, liquid, spicy, etc.). In this case, the food bolus usually does not enter the respiratory tract, but swallowing is difficult, and its movement through the esophagus is accompanied by unpleasant and painful sensations.

With dysphagia of the esophagus, the act of swallowing is not disturbed, but the passage of the food bolus is accompanied by pain in the upper abdomen, heartburn, and sometimes belching. There is an unpleasant aftertaste in the mouth, regurgitation is observed - throwing the contents of the stomach into the pharynx and oral cavity. Regurgitation is aggravated when the body is inclined, as well as during sleep, especially if the meal was less than two hours before bedtime. Symptoms of dysphagia in esophagitis may include hoarseness, increased salivation, and choking. Esophageal dysphagia is more often caused by solid food, its distinctive feature is that drinking water facilitates the process, and when taking liquid or mushy food, the symptoms of dysphagia are less pronounced, although esophageal dysphagia with esophagitis can also occur when taking liquids.

Diagnosis of dysphagia

Since dysphagia is a symptom of a disease and not an independent disease, a thorough diagnosis is necessary to identify the disease that caused the dysphagia. First, a gastroenterological examination is carried out, the main method of which in this case is FGDS - fibrogastroduodenoscopy, an endoscopic examination that allows you to examine the mucous membrane of the upper part of the gastrointestinal tract and identify the existing pathology. If a tumor or ulcer is detected, a biopsy is performed followed by a histological examination, and if signs of esophagitis are found, the contents of the esophagus are taken for bacteriological culture in order to identify the pathogen.

In the event that the cause of dysphagia has not been found with the help of a gastroenterological examination, a neurological examination is performed, revealing the affected nervous structure.

Treatment of dysphagia

Treatment of dysphagia is reduced to the use of local remedies that alleviate its symptoms, since the main therapeutic measures are taken in relation to the disease that caused the dysphagia.

Often, treatment consists of emergency care for acute symptoms of dysphagia. So, in the case of true dysphagia, it is first necessary to thoroughly clean the airways from food that has entered them, making sure that the patient does not suffocate. Further treatment of true dysphagia is carried out in a hospital, in severe cases, food and water are introduced into the esophagus through a tube.

Urgent treatment of dysphagia caused by inflammation of the esophagus consists of taking aluminum-containing antacids (acid-reducing, so-called "heartburn medicines" such as Phosphalugel, Almagel, etc.) or taking Zantac's effervescent tablet dissolved in a glass of water. The subsequent treatment of dysphagia consists in the treatment of esophagitis.

With dysphagia of the esophagus, certain rules of eating behavior and diet must be observed. So, fractional meals in small portions are recommended (at least 4 times a day), food should not be dry and hard, it must be chewed thoroughly. Eating hastily and dry food is prohibited. After eating, it is necessary to avoid bending forward for 1.5-2 hours to avoid regurgitation. The last meal should be no later than 2 hours before bedtime.

If the patient has esophageal dysphagia, his diet should consist of easy-to-digest foods: vegetables, boiled or steamed, lean meats, fish and poultry, and preference should be given to white meat, fatty, fried and smoked foods, as well as spicy foods are excluded. and spicy. Fast food and all kinds of fizzy drinks, as well as strong tea and coffee, are prohibited. Alcohol is completely excluded. Coarse vegetable fiber should also be avoided. Dairy and sour-milk products are recommended, in general, preference should be given to a milk-vegetable diet, with the addition of mucous soups and cereals.

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The information is generalized and is provided for informational purposes only. Seek medical attention at the first sign of illness. Self-medication is dangerous to health!

Comments on the material (30):

1 2

Quoting Oleg:

Hello Oleg.
You still need to find out the reason for this condition. Either find out from the doctors where you were treated, or get tested elsewhere.

Quoting Xenia:

Hello! I have such a problem, I constantly lack air, I can’t eat and drink any food normally, as I start to suffocate. like something is in the throat. throat muscles as if stretched and choked. This is the second year. tell me what to do...

Hello Xenia.
Consult a doctor and undergo an examination to find out the cause of this condition.

Quoting Xenia:

Already contacted no one plainly says the reason.

There is neurogenic dysphagia, i.e. due to nerve damage, and psychogenic - caused by mental factors (strong stress, for example). You need to contact a neurologist to rule out damage to the nervous system that could lead to dysphagia. If everything is in order on this side, you may need the help of a psychotherapist.

Quoting Olive Branch:

Advise please to what expert to go. While eating, when I start drinking, everything is normal, but when I eat in my throat, the feeling is like an hourglass, it gets stuck and slowly passes down the throat. I feel like it's dysphagia. At this time, I begin to cough and expectorate clear mucus similar to sputum. I did X-rays with a contrast agent, everything was normal. I looked at the thyroid. Gastroendoscopy is also normal. Tell me who else to go and see. At home, I scroll all the food in a blender. I can't eat well at work. There can be no talk of a cafe. I don't think this will ever end. Thanks in advance.

You need to contact a neurologist.

Anastasia / 06 Sep 2017, 21:04

Quoting Oleg:

Good evening. I ran into the same problem. I had a stroke in 2000. I walked badly with speech, too, there were problems. But all these years there was no deterioration, but on the contrary. Then came dry mouth. called the doctor. I passed the tests, she said that maybe I have some kind of latent infection, which does not manifest itself in any way. And she prescribed me the antibiotic "Levoximed". I started taking it and I started having problems with swallowing. every day stronger and stronger. I told the doctor. She told me to take it to the end. At the end, I was completely twisted .. I was admitted to the hospital. They shrugged and put a probe through my nose. And they said everyone will now eat with a syringe. And they discharged me ... in short, no specifics, and left me alone with my problem. And what to treat, to whom to turn, I don’t even know .... Tell me what should I do?

Oleg, you need to contact a speech therapist for help. This specialist helps not only restore speech, but also the function of swallowing.

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Relevance of the topic: Differential diagnosis of dysphagia syndrome is one of the important and complex problems in gastroenterology. 2-5% of the population of industrialized countries complain of swallowing disorders. Dysphagia is the cause of 3-4% of visits to general practitioners and 10% of visits to a gastroenterologist. In 25% of patients presenting such complaints, the pains turn out to be functional, and in other cases - organic, and moreover, every 10th situation is considered as requiring surgical intervention.

Thus, the general practitioner will often have to deal with issues of tactics and strategy regarding dysphagia syndrome. A number of patients (with tumors, strictures, hernias) may need help in a surgical setting, hospitals. Another category of patients with a chronic variant of the dysphagia syndrome requires reasonable conservative treatment.

Purpose: To be able to make a preliminary diagnosis and outline management tactics in patients with dysphagia syndrome.

Dysphagia is terminologically defined as difficulty or discomfort when swallowing. This is perceived by the patient as a sensation of "sticking" of food when passing through the oral cavity, pharynx or esophagus.

The normal transport of the food bolus through the swallowing canal depends on the size of the bolus, the diameter of the canal, the peristaltic contraction and the state of the swallowing center, which ensures normal relaxation of the upper and lower esophageal sphincters during swallowing and suppression of persistent contractions in the body of the esophagus. In an adult, the esophagus, due to the elasticity of its wall, can stretch to more than 4 cm in diameter. In cases where the esophagus is not able to stretch to a lumen diameter of more than 2.5 cm, dysphagia develops. In the same cases, when it cannot be stretched over 1.3 cm in diameter, a violation of swallowing will be mandatory. The discrepancy between the size of the food bolus and the diameter of the esophagus or external compression of the lumen of the swallowing canal leads to mechanical dysphagia, and swallowing disorders due to the pathology of the muscles of the swallowing apparatus, its regulation by the nervous system, the lack of coordinated peristaltic contractions of the esophagus and adequate suppression of the swallowing center - to motor dysphagia.

The causes of dysphagia are many and varied. From the main goals, namely, the timely establishment of a diagnosis and the appointment of adequate treatment, it follows that it is necessary to consider the semiotics of swallowing disorders. First of all, the localization of swallowing disorders requires clarification. In this regard, oropharyngeal and esophageal dysphagia are isolated (see table).

Difficulty swallowing, or dysphagia, is a condition in which incoming food cannot move through the esophagus as a result of functional or organic disorders.

The problem is often accompanied by malfunctions in the activity of the digestive system and requires immediate medical attention for timely elimination.

Dysphagia not only brings inconvenience to a person, but can also be a symptom of a serious illness.

There are three forms of pathology:

1.organic look(due to diseases of the upper gastrointestinal tract and adjacent organs);

2.functional form(for disorders of the nervous system that cause difficulty in swallowing due to impaired control of the functions of the esophagus);

3.true view.

1. Causes of pathology

Factors causing difficulty swallowing:

• The presence of a foreign body in the esophagus;
• Injuries of the esophagus;
• Tumors of the oropharynx;
• Angina;
• Anomalies of development;
• Burns of a different nature - alkaline, acid or chemical;
• Esophagitis - inflammatory lesions of the mucous membrane of the esophagus;
• Quincke's edema;
• Plummer syndrome;
• aortic aneurysm;
• Connective tissue pathologies - dermatomyositis, systemic scleroderma, systemic lupus erythematosus;
• Pathologies of the esophagus - Diverticula of the esophagus, Achalasia of the cardia, Gastroesophageal reflux disease;
• Cancer of the stomach or esophagus.

To accurately determine the causes of dysphagia and eliminate them, you should contact a specialist for diagnosis.

2. Symptoms of the disease

The main signs of dysphagia include:

There are 4 stages of dysphagia:

1. Inability to swallow certain solid foods.
2. Hard food cannot be swallowed. Swallowing semi-liquid and liquid food is preserved.
3. It is possible to swallow only liquid food.
4. Swallowing becomes completely impossible.

To make a correct diagnosis, consultations of the following specialists may be required - an otolaryngologist, a gastroenterologist, a neurologist and an oncologist.

3. Diagnosis of pathology

Tests for difficulty and discomfort in swallowing include:

• Esophagogastroduodenoscopy - examination using a special apparatus of the stomach, esophagus and duodenum and, if necessary, taking a fragment of the esophageal mucosa for further examination (biopsy).
• Laryngoscopy - examination of the back of the throat with an endoscope.
• X-ray examination of the esophagus.
• Ultrasound examination of the abdominal organs to identify the condition of organs whose lesions can cause dysphagia.
• Irrigoscopy - an x-ray of the esophagus using a special liquid.
• Electroencephalography of the brain, if a pathology of the nervous system is suspected in the absence of mechanical factors of damage to the esophagus.

4. Treatment of dysphagia

To get rid of the pathology, complex treatment is used, depending on the cause that caused the violation.

Medications include:

• Antibacterial drugs for infections of the esophagus and pharynx of bacterial origin.
• Proton pump inhibitors - medical drugs to reduce the acidity of gastric contents during inflammation of the esophagus - Almagel, Phosphalugel.

The patient is prescribed symptomatic treatment to facilitate the process of swallowing food.

With dysphagia, food can enter the respiratory tract. This requires emergency medical care to clear the respiratory tract to eliminate the threat to human life.

Surgery is necessary to eliminate difficulty in swallowing in the presence of a tumor or burn narrowing of the esophagus.

A special diet helps to alleviate the condition, indispensable for dysphagia during the recovery period after a stroke or for a tumor that cannot be removed.

The rules for eating include:

• food in small portions and pieces;
• thorough chewing of food;
• drinking large amounts of liquid;
• avoid taking alcoholic beverages.

Remember! After eating, physical activity, especially bending over, is undesirable. The last meal should be at least 3 hours before bedtime.

• too high or low food temperature;
• spicy, sour, fried, smoked foods;
• coffee;
• strong tea;
• fast food;
• fizzy drinks.

If you have problems with swallowing, do not eat dry food. It is useful to include in the diet lean meat and fish, white poultry meat, steamed vegetables and fruits, dairy products.

5. Prevention of dysphagia

In order to reduce the likelihood of developing pathology, it is necessary to follow simple rules and recommendations:

6. Forecast

The prognosis is mostly favorable, it depends entirely on the cause of the pathology and the stage.

Dysphagia is a violation of a complex reflex swallowing act. This is not a separate nosology, but a syndrome that manifests itself in many diseases. Patients complain of difficulty in swallowing food, pain in the retrosternal region, salivation, belching, heartburn. In case of violation of the act of swallowing, symptoms associated with the ingress of food into the respiratory tract are not uncommon, which is manifested by coughing, hoarseness. The tactics of the doctor is aimed primarily at identifying the causes.

To do this, pharyngoscopy, radiography of the esophagus with contrast, measurement of pH indicators and esophageal manometry are used. After differential diagnosis and detection of a disease that occurs with a dysphagia syndrome, an etiotropic conservative or surgical treatment is prescribed.

Esophageal dysphagia: symptoms

Esophageal dysphagia is most often caused by esophageal diseases, diseases of the gastrointestinal tract, pathology of the mediastinal organs.

Acute esophageal dysphagia occurs as a result of:

• allergic edema (Quincke's edema);
• obturation.

Causes of esophageal dysphagia:

• The narrowing of the lumen of the esophagus causes cancer of the esophagus (stomach cancer with localization in the cardia also manifests itself), GERD. Cicatricial narrowing occurs after chemical burns, radiation therapy for thoracic oncology.
• When squeezing the esophagus with tumors of the chest organs (cancer of the lung, bronchi), enlarged mediastinal lymph nodes, paraesophageal, cardiac pathology with severe myocardial hypertrophy.
• Violation of the coordinated contraction of the muscles of the esophagus can be a sign of achalasia, total spasm of the esophagus, diabetes mellitus, scleroderma.
• Infectious diseases (tuberculosis), uncontrolled intake of certain drugs (calcium antagonists, nitrates) can lead to a violation of the peristalsis of the esophagus.

Symptoms of esophageal dysphagia:

• in the initial stage of the disease, patients complain of;
• appear retrosternal pain, salivation, often heartburn, dry cough, hoarseness;
• as the symptoms progress, the symptoms increase, there is difficulty in swallowing soft food, and then liquids.

Types of dysphagia

All diseases that occur with dysphagia syndrome, depending on the anatomical level of swallowing disorders, are divided into:

1. Oropharyngeal (oropharyngeal) dysphagia is a violation of the formation of a food coma and its advancement into the pharynx, in this case, the initial swallowing movements are disturbed.

The causes may be neurological pathology, thyromegaly, lymphadenopathy, oncological diseases of the head and neck, degenerative processes of the spine. Main symptoms:

• cough;
• nasal regurgitation;
• bouts of suffocation.

Treatment depends on the causes of this syndrome.

1. Esophageal (esophageal) dysphagia is a violation of the movement of food from the pharynx into the stomach. The causes of the disease are narrowing or compression of the esophageal tube, as well as a violation of its motility.

In addition, all dysphagia is divided into:

• sharp;
• chronic

By the nature of the flow:

• intermittent;
• permanent;
• progressive, with increasing clinic.

Dysphagia - what is it

Dysphagia (Greek dys - denial, phagein - to eat) is the general name for a swallowing disorder.

Dysphagia is a syndrome (complex of symptoms), manifested by a violation of the act of swallowing.

Oropharyngeal dysphagia

Oropharyngeal dysphagia is also called "upper", with this form of dysfunction, the oral and oropharyngeal phases of swallowing are disturbed.

Oropharyngeal dysphagia syndrome includes the following symptoms:

• difficulty at the very beginning of swallowing;
• return of food through the nasal passages;
• cough;
• asthma attack;
• neurological diseases leading to oropharyngeal dysphagia often occur with dysarthria (impaired articulation and pronunciation) and diplopia (impaired function of the visual muscles);

Causes of oropharyngeal dysphagia:

1. Obstruction of the esophagus.

• various infectious processes (tonsillitis, pharyngitis, abscesses);
• enlargement of the thyroid gland (thyroid megaly);
• various lymphadenitis;
• Zenker's diverticulum;
• various types of myositis and fibrosis;
• cervical osteochondrosis;
• oropharyngeal malignancy;

1. Violation of the conduction of nerve impulses to muscle fibers:

• CNS diseases (brain tumors, stroke, Parkinson's disease);
• a disorder in the conduction of a nerve impulse to smooth muscles (VPS dysfunction).

1. Psychosomatic disorders (neurosis, various functional disorders).

Treatment of oropharyngeal dysphagia depends on the etiology of the disease.

• degenerative diseases of the central nervous system;
• previous diseases (strokes, head injuries, diseases of the gastrointestinal tract);
• oncological diseases;
• the presence of severe chronic diseases (diabetes mellitus, coronary artery disease, hypertension).

Dysphagia in children

Dysphagia in children has some peculiarities. First of all, this is due to the diseases that cause this syndrome.

The causes are the following pathologies:

1. Cerebral palsy is the general name for a large group of diseases that have in common damage to the structures of the brain responsible for voluntary movements.
2. Athetosis (hyperkinesis) - involuntary movements in individual muscle groups, occurs when subcortical structures are damaged. It appears immediately after birth, is the result of birth trauma, nuclear jaundice.
3. Various congenital pathologies of the oral cavity and nasopharynx.
4. Infectious lesions of the pharynx, larynx, esophagus.
5. Consequences of surgery.
6. Oncological pathology.

The efforts of doctors are aimed at treating the disease that caused dysphagia and at eliminating or reducing the severity of this syndrome.

Particular attention is paid to neurological pathology, since these diseases have not only medical, but also social significance. A whole program of rehabilitation of patients with cerebral palsy has been developed. Rehabilitation measures begin almost from the first days of life (drug therapy, massage, exercise therapy, physiotherapy procedures are carried out). From the age of three, a speech therapist joins the treatment.

Dysphagia after fundoplication

In severe forms of GERD, a fundoplication operation is performed - this is an anti-reflux operation, which consists in the fact that a special cuff is formed around the esophagus from the bottom of the stomach, preventing the refluxate from being thrown into the esophagus (). The operation has proven itself and gives good results. However, after fundoplication in the early postoperative period, dysphagia and moderate epigastric pain are often observed. This is due to the fact that a “new” valve of the esophagus is being formed and the body is adapting to it. These discomforts go away without any treatment.

Functional dysphagia

Functional dysphagia is a manifestation of various neuroses. This form of pathology can manifest itself at any age. People suffering have a special psychological characteristic - they:

• suspicious;
• anxious;
• subject to various kinds of phobias.

In children, functional dysphagia of the esophagus and pharynx may be present from a very young age. It is often accompanied by the following symptoms:

• poor appetite;
• frequent regurgitation, vomiting
• bad night sleep.

Without treatment, by the age of 7, children experience dystrophy, increased fatigue, poor tolerance of physical and mental stress.

Diagnosis of dysphagia

The dysphagia syndrome itself usually does not cause diagnostic difficulties. All the efforts of doctors are aimed at identifying the disease that caused dysphagia. In terms of diagnosis, the following examinations are carried out:

1. Pharyngoscopy - this method allows you to identify the causes of oropharyngeal dysphagia: glossitis, tonsillitis, neoplasms, foreign bodies. Pharyngoscopy is complemented by indirect laryngoscopy, the method allows you to identify the pathology of the epiglottis.
2. allows you to identify violations of the motility of the esophagus,.
3. EFGS reveals foci of inflammation, areas suspicious for. If necessary, a tissue biopsy is performed for morphological examination.
4. Long-term measurement of the pH of the medium inside the esophagus is the most reliable method for detecting GERD; esophageal manometry is performed (to determine abnormalities in the functioning of the ESP).
5. Laboratory research methods are non-specific:

• in the peripheral blood, a small leukocytosis, anemia, an increase in ESR can be determined;
• in venous blood, a decrease in total protein, dysproteinemia is most often observed;
• stool testing for occult blood.

In order to identify neurological pathology, an in-depth neurological examination is performed. If clinical diagnosis is in doubt, instrumental diagnosis is carried out:

• CT scan of the brain;

If cardiac and pulmonary pathology is suspected, the following is performed:

• chest x-ray;
• echocardiography.

Treatment of dysphagia is carried out after the final diagnosis.

Degrees of dysphagia

According to the severity of the clinical picture, the following degrees of dysphagia are distinguished:

1. The patient has difficulty swallowing hard, dry food.
2. The patient can only swallow liquid food.
3. Swallowing not only solid, but also liquid food is disturbed.
4. Unable to swallow any food.

Treatment

The doctor's tactics in the treatment of dysphagia is determined by the cause of the disease and the severity of the syndrome. The efforts of doctors are aimed at the speedy restoration of the act of swallowing and the prevention of aspiration complications.

Acute cases of dysphagia require urgent care:

• the foreign body is immediately removed.
• desensitizing therapy is urgently carried out.

With a long course of the disease, complicated by dysphagia, a full course of etiopathogenetic treatment is carried out. Of the medications used:

1. Means for improving the neuroregulation of the act of swallowing. In degenerative diseases, dopamine agonists and precursors, central H-anticholinergics are prescribed. Membrane stabilizers, neuroreparants, and neuroprotectors are widely used in strokes.
2. calcium antagonists. The drug reduces the concentration of intracellular calcium, due to this, the spasm of muscle fibers (diffuse esophageal spasm, achalasia) is eliminated, thereby improving the passage of food.
3. Antisecretory drugs. These drugs are used for GERD and eosinophilic esophagitis with dysphagia. Antacids, PPIs, IGRs are used.
4. With an infectious etiology of the disease (tonsillitis, abscesses, pharyngitis), antibiotic therapy is indicated.
5. In the treatment of functional disorders of swallowing, traditional medicine is widely used.

In some cases, the elimination of dysphagia is possible only surgically. In case of neoplasia that close the lumen of the esophagus or compress it, a resection or removal of a pathologically altered organ (removal of the stomach, lung) is performed, followed by radiation and chemotherapy.

Also, patients with Zenker's diverticulum can be treated only in surgery; timely cricopharyngeal myotomy practically cures dysphagia.

Dysphagia(gr. dys-+ phagein- eat, swallow) - this is difficulty swallowing; a symptom of diseases of the esophagus, adjacent organs or neurogenic disorders of the act of swallowing. Sometimes the violation of swallowing reaches the degree of aphagia (complete inability to swallow).

The causes of dysphagia can be diseases and injuries of the pharynx (dysphagia is possible, for example, with acute tonsillitis, paratonsillar abscess, allergic edema of the tissues of the pharynx, with a fracture of the prelingual bone - dysphagia Valsalvae), lesions of the nervous system and muscles involved in the act of swallowing (with bulbar paralysis, rabies, botulism, tetany, neuritis of the hypoglossal nerve, dermatomyositis, etc.), as well as functional disorders of the regulation of swallowing in neuroses; compression of the esophagus by volumetric pathological formations in the mediastinum (tumors, significant enlargement of the lymph nodes), due to mediastinitis, very rarely - abnormally located right subclavian artery or brachiocephalic trunk (dysphagia lusoria), double aortic arch or osteophytes in osteochondrosis of the spine. Among the causes are also various diseases and lesions of the esophagus (trauma, burns, tumor, inflammatory and degenerative processes).

THEME #4

DYSPHAGIA SYNDROME IN CONGENITAL AND ACQUIRED DISEASES OF THE ESOPHAGUS OF A NON-TUMOR NATURE

The purpose of training

know:- the main symptoms of diseases of the esophagus of a non-tumor nature, detected during questioning, examination and study of the data of the patient's laboratory and instrumental examination;

Differential diagnostic signs of dysphagia in various diseases of the esophagus of a non-tumor nature;

Indications and contraindications for bougienage of the esophagus, planned and emergency surgical intervention for various diseases of the esophagus of a non-tumor nature;

Options for surgical interventions, the main stages of operations and determine the most optimal method of intervention for a particular patient in various diseases of the esophagus of a non-tumor nature.

After conducting a lesson on this topic, the student should be able to:

Determine indications and contraindications for surgical intervention in diseases of the esophagus of a non-tumor nature;

Evaluate the effectiveness of the surgical treatment and, if necessary, correct it;

After conducting a lesson on this topic, the student should own:

Methods of general clinical examination of patients with dysphagia syndrome in congenital and acquired diseases of a non-tumor nature;

Interpretation of the results of laboratory, instrumental diagnostic methods in patients with dysphagia syndrome in congenital and acquired diseases of a non-tumor nature;

An algorithm for making a preliminary diagnosis for patients with dysphagia syndrome in congenital and acquired diseases of a non-tumor nature, followed by their referral for additional examination and to specialist doctors;

An algorithm for making a clinical diagnosis in patients with dysphagia syndrome in congenital and acquired diseases of a non-tumor nature;

The relationship between the goals of teaching this and other disciplines, as well as teaching on this and previously studied topics is shown in diagrams 7, 8.

Information part

Dysphagia in 25% of patients is functional, and in 75% of patients it is caused by an organic disease of the pharynx, esophagus and cardia. Every 10th case of dysphagia is due to conditions requiring surgical intervention.

Diagnostic criteria for functional dysphagia: a feeling of "stuck" or abnormal movement of solid or liquid food through the esophagus; lack of evidence that the cause of the symptom is gastroesophageal reflux; absence of esophageal motor disorders caused by structural (histopathological) changes.

Functional dysphagia is often manifested by the retention of liquid food, and the passage of solid food is less impaired, which creates a picture of the so-called paradoxical dysphagia.

The causes of dysphagia are numerous. The study of the features of swallowing disorders, in particular

Scheme 7.

Scheme 8.

and their localization. In this regard, oropharyngeal and esophageal dysphagia are distinguished.

Patients with oropharyngeal dysphagia complain about the accumulation of food in the mouth or the inability to swallow it, or difficulty within 1 second after swallowing. These patients have aspiration before, during, or after swallowing. Aspiration during swallowing may cause coughing or choking. Possible nasopharyngeal regurgitation, twang, ptosis,

photophobia and visual disturbances, as well as weakness, increasing towards the end of the day. The causes of oropharyngeal dysphagia are aphthae, candidiasis, cerebrovascular accident. It rarely occurs in Parkinson's disease. globus hiSTericus, pseudobulbar palsy, myasthenia gravis, Sjögren's disease, poliomyelitis, botulism, syringobulbia.

With dysphagia due to damage to the esophagus, sensations of difficulty in swallowing are localized retrosternally or in the xiphoid process, occur after several consecutive swallowing acts. In the presence of esophageal dysphagia, patients cannot always determine the area of ​​the lesion. So, only 60-70% of them can correctly indicate the level of food retention in the esophagus. Determination of the time elapsed from the moment of swallowing to the onset of dysphagia can serve as a more objective and simple initial assessment of the level of damage. Dysphagia of the cervical esophagus manifests itself immediately after the swallow - after 1-1.5 s, dysphagia of the middle third of the esophagus - after 4-5 s, distal dysphagia - after 6-8 s.

Clarification of the localization of dysphagia is of diagnostic value when patients describe it as tightness in the chest area, more often behind the sternum, which usually corresponds to the level of esophageal obstruction.

By duration, intermittent (paroxysmal) and persistent (permanent) dysphagia are distinguished. The first is due to hypermotor dyskinesia of the esophagus. Such dyskinesia often accompanies the course of diseases such as hiatal hernia, esophagitis of various origins, tumors of the esophagus. Permanent dysphagia is observed in most cases in patients with organic pathology and is manifested by difficult passage of predominantly solid food.

The extreme severity of dysphagia is aphagia, in which there is a complete jamming of the alimentary canal, which requires urgent instrumental or surgical intervention.

odynophagy- painful swallowing.

phagophobia(fear of swallowing) may be associated with odynophagia or with the fear of aspiration of food during swallowing in patients with paralysis of the pharynx, tetanus, rabies, also observed in hysteria, up to refusal to swallow.

A type of psychogenic dysphagia is globus hystericus- hysterical lump in the throat in patients with anorexia nervosa.

Clinical picture and diagnosis. Symptoms associated with dysphagia are of great diagnostic value. Nasal regurgitation and tracheobronchial aspiration during swallowing are signs of pharyngeal muscle paralysis and tracheoesophageal fistula. If dysphagia is preceded by a hoarse voice, the primary lesion is localized in the larynx. A hoarse voice may be due to laryngitis secondary to gastroesophageal reflux. Hiccups suggest damage to the distal esophagus. Vomiting is characteristic of an organic lesion of the distal esophagus (achalasia cardia, cardioesophageal cancer, esophageal strictures, etc.). Dysarthria, dysphonia, ptosis, tongue atrophy, and overactive masticatory muscle contractions are hallmarks of bulbar and pseudobulbar palsy.

The differential diagnostic algorithm requires not only an analysis of the patient's complaints, but also a detailed analysis of the history of the disease. Long-term heartburn preceding the onset of dysphagia may indicate the development of peptic stricture of the esophagus. Short transient dysphagia may be due to the inflammatory process. The type of dysphagia also depends on the consistency of the food that causes discomfort when swallowing. Difficulties that arise when swallowing only solid food indicate organic dysphagia. At the same time, a stuck lump can be pushed through a narrowed area of ​​\u200b\u200bthe esophagus by drinking any liquid. Liquid food is worse in violation of motor function. With a pronounced decrease in the lumen of the swallowing canal, dysphagia develops with the use of both solid and liquid food.

During physical examination of patients with dysphagia, special attention should be paid to examination of the oral cavity and pharynx, palpation of the thyroid gland. It is necessary to carefully examine the lymph nodes of the liver to exclude the metastatic nature of their lesion, lungs - to exclude acute aspiration pneumonia and skin - to exclude scleroderma, other collagen and skin diseases that affect the mucous membranes and possibly involve the esophagus (pemphigus, epidermolysis bullosa and etc.).

In diseases of the pharynx and organic lesions of the nervous system, dysphagia is usually combined with other subjective and objective symptoms that facilitate the recognition of the underlying disease. Dysphagia may be associated with damage to the recurrent nerve, leading to the development of paresis of the larynx and dysphonia. This

a special form is called dysphagia lusoria (Lusoria) it was first described by David Bayford 1 . Usually, in addition to disrupting the passage of food through the esophagus, this type of dysphagia is characterized by pain in the chest, difficulty breathing caused by compression of the trachea.

In the early stages of some diseases of the esophagus (including tumors), dysphagia may be the only subjective manifestation of the disease, and distinguishing between functional dysphagia and organic dysphagia can present significant difficulties. It is usually taken into account that functional dysphagia is characterized by episodic occurrence or intermittent course and is provoked by swallowing not so much dense as irritating, for example hot or cold, food (neurotic dysphagia can be observed when swallowing liquid food and even water, but absent when swallowing dense food mass). Organic dysphagia is characterized by the absence of remissions and dependence on the density of food intake. Drinking water with food usually brings relief.

1 David Bayford coined the Latin term in 1974 arteria Lusoria, this is how he literally described the anomalous right subclavian artery: “7t may be called lusoria, from Lusus Naturae that gives rise to it", which literally translated from Latin means "freak from birth." David Bayford not only introduced the concept of medical terminology arteria Lusoria, but also described in detail dysphagia, the most common syndrome observed in such patients.

serous, hemorrhagic or mucopurulent exudate, erosions or ulcers of various sizes and shapes, fibrinous films, easily or with difficulty separated from deeper tissues. An x-ray examination reveals a decrease in the tone of the esophagus, edematous and thickened folds of the mucous membrane, and in the presence of ulcerative lesions, a depot of barium suspension.

As a leading syndrome, dysphagia is noted in patients with such a relatively rare disease as achalasia of the cardia. Achalasia cardia(from Greek. a- absence, chalasis- relaxation) - a disease based on the absence of reflex relaxation of the lower esophageal sphincter during swallowing, accompanied by a violation of the tone and peristalsis of the thoracic esophagus, which results in dilatation of the upper esophagus. There are two types of achalasia cardia.

Type I is characterized by a moderate narrowing of the distal esophagus and a slight suprastenotic expansion of the esophagus (up to 6 cm). At the same time, its cylindrical or oval shape is preserved.

With type II achalasia cardia, there is a pronounced narrowing of the distal part of the esophagus and its significant suprastenotic expansion (sometimes up to 16-18 cm), which is why the esophagus often takes an N-shape. Depending on the type of dyskinesia of the thoracic esophagus, hypermotor and hypomotor forms of achalasia cardia are distinguished, and depending on the severity of the clinical course of the disease, the stages of compensation and decompensation.

In addition to dysphagia, which especially often occurs when eating apples, meat, fresh bread, patients complain of lengthening the time of eating. To improve the passage of food, patients often resort to certain methods, for example, they drink a glass of water in one gulp, arch their torso back, raise their arms up, which facilitate the passage of food through the esophagus. As the severity of dysphagia increases and the esophagus expands, regurgitation, esophageal vomiting and aspiration complications join. With hypermotor dyskinesia of the thoracic esophagus, as well as due to its overflow, pain behind the sternum occurs. With rare episodes of dysphagia, the general condition of patients does not significantly suffer (compensation stage). With a pronounced violation of the passage of food through the esophagus, persistent regurgitation and esophageal vomiting, weight loss of patients can be observed, up to the development of cachexia (decompensation stage).

An x-ray examination shows the presence of a large amount of contents in the esophagus on an empty stomach, as well as a slowdown in the passage of a suspension of barium sulfate from the esophagus to the stomach. In the early stages of the disease, the intake of nitroglycerin by patients improves the evacuation of food from the esophagus to the stomach. An important diagnostic symptom is the absence of a gas bubble of the stomach. The distal esophagus is narrowed. In the later stages of the disease, a smooth narrowing is noted, turning into a suprastenotic (fusiform or S-shaped) expansion of the esophagus, giving an x-ray symptom of a "mouse tail" or "carrot tip" or, in the terminology of American authors, "bird's beak".

Endoscopic examination is carried out after careful preparation of patients and washing the esophagus with a thick gastric tube in order to remove stagnant contents. Endoscopy reveals an expansion of the esophagus (often with atony of its wall), signs of congestive esophagitis (edema and hyperemia of the mucous membrane), sometimes with areas of epithelial metaplasia (leukoplakia). The entrance to the cardia is closed. However, the endoscope is passed into the stomach without much resistance, unlike the narrowing caused by a malignant tumor. Manometry findings of insufficient relaxation of the lower esophageal sphincter and decreased or absent peristalsis in the distal esophagus support suspected achalasia.

About 2% of all cases of dysphagia are due to the presence of esophageal diverticula - sac-like protrusions of its wall facing the mediastinal lumen. They can be congenital and acquired, true (the wall of which is represented by all layers of the esophagus wall) and false (formed by protrusion of the mucous and submucosal layers through a defect in the muscular layer). Due to the increase in pressure in the lumen of the esophagus, diverticula are formed, called pulsion diverticula. Diverticula resulting from adhesions between the esophagus and surrounding organs are referred to as traction diverticula. Diverticula can be located in the posterior wall of the distal pharynx (pharyngoesophageal, or Zenker), middle third (bifurcation), or lower third of the esophagus (epiphrenal). Dysphagia is the main complaint of patients with Zenker's diverticula. It is characteristic that the first and second throats do not cause any difficulties. The sensation of an obstruction appears during the subsequent filling of the diverticulum. There may also be complaints of regurgitation.

food, bad breath, and a mass in the neck. Zenker's diverticulum is usually recognized radiographically. Endoscopic examination is contraindicated due to the risk of perforation of the diverticulum.

Among the less common diseases that occur with dysphagia syndrome, iron deficiency hypochromic anemia should be noted. Clinically, sideropenic dysphagia is manifested by difficult passage of solid food, and as the disease develops, liquid food against the background of general weakness and fatigue. Patients complain of itching of the skin in the anus and perineum. Objectively pay attention to varying degrees of pallor of the skin and mucous membranes, trophic disorders: dry skin, brittle hair, nails, the presence of colonychia. The mucous membrane of the oral cavity is pale, thinned, dry. Often, cracks appear in the corners of the mouth, and angular stomatitis develops. The tongue also undergoes characteristic changes: the papillae are smoothed out, the tongue becomes varnished or crimson.

With the help of laboratory research methods, as a rule, a decrease in the serum level of non-hemoglobin iron is detected. In addition, to differentiate sideropenic dysphagia, X-ray methods of research, observation in dynamics, treatment are used. exjuvantibus. Therapy includes iron preparations in combination with hydrochloric acid, pepsin, B vitamins, folic, ascorbic acid, and symptomatic treatment is also used.

Damage to the esophagus can occur against the background of systemic diseases of the connective tissue. In particular, with scleroderma, the muscular membrane and submucosa of the esophagus undergo fibrinoid degeneration, resulting in the development of dysphagia, accompanied by burning behind the sternum. The dysphagia associated with dermatomyositis is usually associated with damage to the muscles of the pharynx.

A possible but extremely rare cause of dysphagia is compression of the esophagus from the outside, such as, for example, as a result of an anomaly of the right subclavian artery, paraesophageal hernia, lymphoma, aortic aneurysm, pericardial effusion, empyema, lung abscess, bronchial cancer, hyperostosis of the cervical vertebrae, enlargement of the thyroid gland, tuberculous lesions of the lymph nodes of the mediastinum, retrosternal goiter, enlargement of the left ventricle of the heart. Some formations that compress the esophagus from the outside can be detected using a plain chest x-ray.

Treatment dysphagia syndrome requires a differentiated approach due to the presence of functional and organic forms.

The main method of treatment of achalasia cardia is balloon pneumocardiodilatation. Contraindications to its use are portal hypertension with varicose veins of the esophagus, pronounced esophagitis, blood diseases accompanied by increased bleeding. Recently, dilatation has been used for 2 days, repeating this procedure 5-6 times. Relapse occurs in 10% of patients. Attempts are also being made to introduce botulinum toxin into the region of the lower esophageal sphincter.

Surgical treatment is carried out according to the following indications:

1) if it is impossible to carry out cardiodilatation (especially in children);

2) in the absence of a therapeutic effect from repeated courses of cardiodilatation;

3) with early diagnosed ruptures of the esophagus that occur during cardiodilatation;

4) with amotile form (III-IV stage according to B.V. Petrovsky);

5) with cancer of the esophagus.

Surgical treatment is subject to 10-15% of patients with achalasia.

Currently, extramucosal cardiomyotomy is used, i. extramucosal Geller cardiotomy from the abdominal access: the muscular membrane of the terminal esophagus is cut longitudinally on the probe for 8-10 cm. Geller cardiotomy is combined with a Nissen fundoplication to prevent the development of peptic esophagitis. In 90% of patients, the results of the operation are good.

Cardioplasty with a diaphragmatic flap according to B.V. Petrovsky is performed from the left-sided transthoracic access. From the dome of the diaphragm cut out a rectangular flap on the leg, without dissecting the esophageal opening of the diaphragm. On the anterior surface of the esophagus and cardia, a T-shaped incision is made in the muscle layer to the submucosa. The transverse incision runs along the anterior semicircle 6-7 cm above the cardia. The vertical incision should be extended to the cardia of the stomach. Then the muscular layer of the esophagus and the serous-muscular stomach are peeled off to the sides, the cardia is expanded with a finger, screwing the wall of the stomach into the lumen of the esophagus. A prepared flap of the diaphragm is sutured into the resulting muscle defect. The aperture of the diaphragm, formed after cutting out the flap, is sutured.

Cardioplasty with the fundus of the stomach is performed from a thoracotomy in the seventh intercostal space on the left. As in the previous operation, the esophagus is mobilized and myocardiotomy is performed. The bottom of the stomach is sutured to the edges of the resulting defect in the muscular membrane of the esophagus. To prevent the development of reflux esophagitis, at least 2/3 of the circumference of the esophagus should be wrapped in the fundus of the stomach. The stomach is sutured to the esophagus with separate silk sutures. Of the complications during surgery, it should be noted the possibility of injury to the mucous membrane during myotomy. In such cases, the mucosa is sutured and the operation is completed as usual.

Treatment of esophagitis includes the appointment of a mechanically, chemically and thermally sparing diet. In destructive forms, patients are transferred to parenteral nutrition. With the development of strictures, the issue of bougienage or esophageal plastic surgery is decided.

A pathology such as axial hernia does not require treatment in the case of an asymptomatic course. With the threat of complications (bleeding, infringement), paraesophageal hernias are subject to surgical treatment.

Patients with asymptomatic diverticula of the esophagus are subject to dynamic observation. Surgical treatment is indicated for patients with large diverticula, as well as with severe clinical symptoms and developed complications.

Surgical treatment is indicated for complications of esophageal diverticulum (diverticulitis, ulceration, fistulas, bleeding, cancer, etc.). In case of pharyngoesophageal diverticulum, only cervical diverticulectomy is currently performed as the most radical intervention in this disease.

With bifurcation and epiphrecal diverticula, a diverticulectomy or invagination of the diverticulum is performed. Diverticulectomy is performed from the right thoracic approach. Specify the area of ​​localization of the diverticulum and dissect the mediastinal pleura. The esophagus is isolated just enough to allow surgery to be performed. In most cases, it is not necessary to take it on a holder. The diverticulum is isolated from the surrounding tissues up to the neck and excised. The hole in the esophagus is sutured, separate sutures are placed on the mediastinal pleura. If the muscular membrane of the esophagus is weakly expressed, then plastic cover of the sutures is required, which is best done with a flap.

diaphragm volume. Diverticulum intussusception often recurs and is therefore used only for small diverticula, mainly in combined operations (for example, in the presence of an epiphrenic diverticulum and hiatal hernia).

Situational task number 1

A 24-year-old patient has been suffering from intermittent dysphagia for 2 years. It occurs, as a rule, after overwork and nervous tension. During the period of dysphagia, moderate pain in the epigastrium is noted. There is no vomit. Appetite saved. General condition is satisfactory (Fig. 24).

What is your preliminary diagnosis? Make a survey plan.

Situational task number 2

A 53-year-old patient complains of periodic dysphagia over the past 2 years. Food has to be washed down with plenty of water. About 1.5 months ago, I noticed a swelling in the neck area on the left, which either increases or decreases. It made the patient go to the doctor (Fig. 25).

What is the preliminary diagnosis and examination plan?

Rice. 24

Rice. 25

Situational task number 3

A 60-year-old patient suffers from pain behind the sternum and along the spine, belching with air and food with an unpleasant odor. Moderate burping has been around for a long time. Sometimes during meals he noted heaviness behind the sternum and in the interscapular space. Recently, belching of air and food with an unpleasant odor, a sensation of a foreign body behind the sternum, have become constant, swallowing and passing food through the esophagus are periodically observed for several hours. After artificially induced vomiting, these phenomena disappear. In vomit - food with a bad smell (rice. 26).

What is the preliminary diagnosis, examination plan and treatment tactics?

Rice. 26

Situational task number 4

A 29-year-old patient complains of severe dysphagia (only water passes), general weakness, weight loss, increased salivation. A year ago, with suicidal intent, I drank vinegar essence. First aid was provided at home, then in the hospital. She was discharged from the hospital after 1 month in a satisfactory condition, food passed freely through the esophagus. Three months after discharge, dysphagia developed, which progressively worsened. The patient lost 11 kg. X-ray revealed the following picture (rice. 27).

What is your diagnosis? What type of surgery will the patient need?

Rice. 27. X-ray of the esophagus of a patient, 29 years old

Rice. 28. X-ray of the esophagus of a patient, 49 years old

Situational task number 5

A 49-year-old patient suffered from severe heartburn, especially at night, and belching for many years. Diagnosed with hyperacid gastritis. Conservative treatment did not help. Periodically, heartburn was accompanied by pain behind the sternum, aggravated by the passage of food. Sometimes during the strengthening of heartburn and retrosternal pain, dysphagia was noted. The result of the X-ray examination is shown in rice. 28.

What is your diagnosis, examination and treatment plan?

Test tasks

1.

1) resection of a segment of the esophagus;

2) diverticulectomy;

4) invagination of the diverticulum;

5) resection of the lower third of the esophagus and cardia.

2. With complicated sliding (axial) hernias of the esophageal opening of the diaphragm, surgical treatment is indicated. Specify an intervention that is a selection operation:

1) crororaphy;

2) resection of the cardia;

3) stem vagotomy;

4) fundoplication according to Nissen;

5) fixation of the esophagus to the anterior abdominal wall.

3. Surgical treatment of a patient with cardiospasm is indicated:

1) in the absence of the effect of cardiodilatation;

2) with rupture of the esophagus during cardiodilatation;

3) with congestive esophagitis;

4) with nocturnal regurgitation;

5) when identifying signs of malignancy.

4. A 30-year-old patient has been suffering for a long time from chest pain radiating to the interscapular space. The pains are aggravated by eating. He notes constant belching and heartburn, which increase sharply when lying down. During heartburn, pain behind the sternum and in the region of the xiphoid process appears or intensifies. ECG is normal.

Your diagnosis:

1) angina pectoris;

2) reflux esophagitis (reflux disease of the esophagus);

3) esophagospasm;

4) an ulcer of the cardial part of the stomach;

5) cancer of the esophagus.

5. Bougienage of the esophagus after an acute burn should begin:

1) for 1-2 days;

2) for 8-9 days;

3) after 3 weeks;

4) after 1 month;

5) after the onset of persistent dysphagia.

6. What research methods are indicated for the detection of esophageal diverticulum:

2) mediastinoscopy;

3) electrokymography;

4) esophagomanometry;

5) esophagoscopy.

7. The indication for surgery for cardiospasm is:

1) the absence of a persistent effect of cardiodilatation (with repeated courses of treatment);

2) rupture of the esophagus during cardiodilatation;

3) impossibility to conduct a cardiodilator into the cardia;

4) esophagitis;

5) segmental spasm of the esophagus.

8. For diverticula of the esophagus, the following operations are used:

1) resection of a segment of the esophagus with a diverticulum and end-to-end esophageal-esophageal anastomosis;

2) excision of the diverticulum with plastic surgery of the esophageal wall with a diaphragm flap;

3) diverticulectomy;

4) invagination of the diverticulum;

5) Operation Dobromyslov-Torek.

9. In a 54-year-old patient, an x-ray examination of the chest cavity revealed loops of the large intestine in the posterior mediastinum. Both domes of the diaphragm and the stomach are in the usual place.

Your diagnosis:

1) Larrey's hernia;

2) sliding hernia of the esophageal opening of the diaphragm;

3) paraesophageal hernia;

4) relaxation of the diaphragm;

5) traumatic hernia of the diaphragm.

10. Specify the most common symptoms of sliding hernia of the esophageal opening of the diaphragm:

1) heartburn;

2) chest pain;

3) symptom of "shoe lace";

4) intermittent intestinal obstruction;

5) melena.

11. What complications are possible with cardiospasm:

1) acute bronchitis;

2) pneumonia;

3) phlegmon of the neck;

4) congestive esophagitis;

5) perforation of the esophagus.

12. A 43-year-old patient complains of pain in the chest and a burning sensation, aggravated after a heavy meal, drinking carbonated water and in the supine position. In the standing position, the pain and burning sensation decrease. In blood tests - moderate hypochromic anemia.

Your diagnosis:

1) chronic gastritis;

2) duodenal ulcer;

3) hiatal hernia with symptoms of reflux esophagitis;

4) stomach cancer;

5) epiphrenic diverticulum of the esophagus.

13. What measures are indicated for a patient with a chemical burn of the esophagus in the acute phase:

1) washing the oral cavity, esophagus and stomach with drinking water;

2) prescribing morphine and sedatives;

3) drinking milk;

4) total parenteral nutrition;

5) the introduction of a permanent gastric tube.

14. Under what conditions are x-ray sliding hernias of the esophageal part of the diaphragm detected:

1) in a standing position;

2) semi-sitting position;

3) Trendelenburg position;

4) with artificial hypotension of the duodenum;

5) in the position on the side.

15. What types of cardiospasm are indicated for surgical treatment:

1) with cardiospasm with a hernia of the esophageal opening of the diaphragm;

2) maintaining the effect of cardiodilatation for 2 years;

3) narrowing of the cardia with an S-shaped lengthening of the esophagus;

4) expansion of the esophagus more than 8 cm;

5) long course, complicated by esophagitis.

16. Patient, 20 years old. About 3 months ago I drank a solution of caustic soda ("by mistake"). Currently, rapidly progressive dysphagia has developed. Radiographically determined local stricture of the middle third of the esophagus with a narrowing of its diameter to 2-3 mm.

Shown treatment:

1) resection of the esophagus;

2) bougienage of the esophagus;

3) extirpation of the esophagus;

4) plastic surgery of the esophagus (stomach, small or large intestine);

5) gastrostomy.

17. What research methods are most informative in the diagnosis of hiatal hernia:

1) Ultrasound of the abdominal organs;

2) radiography of the esophagus and stomach with barium;

3) fluoroscopy of the esophagus and stomach in the Trendelenburg position;

5) fluoroscopy of the esophagus and stomach in the vertical position of the patient;

6) esophagomanometry.

18. What operations are used for diverticula of the esophagus:

1) resection of the esophagus;

2) diverticulectomy;

3) operation Dobromyslov-Torek;

4) invagination of the diverticulum;

5) resection of 1/3 of the esophagus and cardia.

19.

1) profuse vomiting of gastric contents;

2) regurgitation while eating;

3) selective dysphagia for certain foods and liquids (apples, oranges, sparkling water, etc.);

4) paradoxical dysphagia;

5) vomiting of undigested food.

20. Which of the following methods of treatment of cardiospasm should be used for persistent and long-term course of the disease:

1) medication;

2) hypnosuggestive;

3) cardiodilation;

4) operational.

21. Specify the most common symptoms of axial hernia of the esophageal opening of the diaphragm:

1) heartburn;

2) chest pain;

3) melena;

4) intestinal obstruction;

5) belching.

22. What research methods are used to diagnose cardiospasm:

1) x-ray examination of the esophagus;

2) sounding of the esophagus;

3) esophagomanometry;

4) mediastinoscopy;

5) esophagoscopy;

6) all of the above;

7) none of the above.

23. Which of the following symptoms are characteristic of cardiospasm:

1) long-term intermittent dysphagia;

2) nocturnal regurgitation;

3) heartburn;

4) sharp progressive weight loss;

5) paradoxical dysphagia;

6) all of the above;

7) none of the above.

24. What complications are possible with cicatricial stricture of the esophagus:

1) chronic esophagitis;

2) bleeding;

3) cancer of the esophagus;

4) polyposis of the esophagus;

5) perforation of the esophagus.

25. A 50-year-old patient suddenly developed acute dysphagia, accompanied by severe pain behind the sternum. A possible reason is:

1) intercostal neuralgia;

2) angina pectoris;

3) strangulated paraesophageal hernia;

4) reflux esophagitis;

5) Larrey's hernia.

26. A 36-year-old patient notes the appearance of chest pains that radiate to the left half of the chest and are accompanied by difficulty in passing food through the esophagus. On the ECG: a decrease in the T wave, slight diffuse changes in the myocardium, sinus rhythm. An x-ray examination of the esophagus and cardia of the stomach without features, the gas bubble of the stomach in the form of an "hourglass", part of it is located above the level of the diaphragm.

Set the diagnosis:

1) diaphragmatic hernia of Larrey-Morgagni;

2) diaphragmatic hernia of Bogdalekh;

3) paraesophageal hernia of the esophageal opening of the diaphragm;

4) subtotal sliding hernia of the esophageal opening of the diaphragm;

5) relaxation of the left dome of the diaphragm.

27. The patient complains of increased salivation, a feeling of scratching in the throat, awkwardness when swallowing, coughing. Periodically after eating, dysphagia and swelling appear on the neck. Sometimes, in order to swallow food, you have to take forced positions, while gurgling sounds are heard, and the swelling disappears. Set the diagnosis:

1) foreign body in the upper third of the esophagus;

2) tumor of the upper third of the esophagus;

3) neck cyst;

4) pharyngeal-esophageal diverticulum;

5) esophageal-bronchial fistula.

Demo Material

1. Radiographs.

2.X-ray tomograms.

4. Bougienage of the esophagus.

5. Dilation of the esophagus.

6. Educational videos.

THEME #5

DYSPHAGIA SYNDROME IN MALIGNANT AND BENIGN TUMORS OF THE ESOPHAGUS

The purpose of training

After conducting a lesson on this topic, the student should know:- the main symptoms of tumor diseases of the esophagus, revealed during questioning, examination and study of laboratory and instrumental examination data;

Differential diagnostic signs of dysphagia in various tumor diseases of the esophagus;

Indications and contraindications for planned and emergency surgical intervention;

Principles of patient management in the preoperative and postoperative periods;

Options for surgical interventions, the main stages of operations, to determine the most optimal method of intervention for a particular patient;

Scheme and rules for filling out a medical history.

After conducting a lesson on this topic, the student should be able to:

Formulate a preliminary diagnosis, a plan for laboratory and instrumental research methods, evaluate the results of analyzes based on the variety of clinical manifestations of these diseases;

Determine the indications and contraindications for surgical intervention in tumor diseases of the esophagus;

Develop a plan of operation and its possible options;

Assign preoperative preparation to the patient depending on the severity and prevalence of the disease, as well as the volume of the planned surgical intervention;

Formulate and substantiate the clinical diagnosis in accordance with ICD-10;

Evaluate the effectiveness of the surgical treatment;

Develop a set of measures for primary and secondary prevention of diseases and their complications;

Assess the patient's ability to work, prognosis for life;

Formulate a discharge diagnosis for the patient based on histological data.

After conducting a lesson on this topic, the student should own:

Methods of maintaining medical accounting and reporting documentation in medical and preventive institutions of the healthcare system;

Assessments of the health status of the population of various age, sex and social groups;

Methods of general clinical examination of patients with dysphagia syndrome in tumor diseases of the esophagus;

Interpretation of the results of laboratory, instrumental diagnostic methods in patients with dysphagia syndrome in tumor diseases of the esophagus;

An algorithm for making a preliminary diagnosis in patients with dysphagia syndrome in tumor diseases of the esophagus;

An algorithm for making a detailed clinical diagnosis in patients with dysphagia syndrome in tumor diseases of the esophagus;

Algorithm for the implementation of basic medical diagnostic and therapeutic measures to provide first medical aid to the population in urgent and life-threatening conditions.

The relationship of learning goals with the learning goals of other disciplines is shown in diagrams 9, 10.

Information part

In the pathogenesis of dysphagia in diseases of the esophagus, it is important esophagospasm, caused by irritation of the altered area of ​​the mucous membrane of the esophagus with a food lump. This is evidenced, for example, by the fact that even with mechanical disorders of the esophagus (cicatricial stenosis, cancer), dysphagia usually occurs before a significant mechanical obstruction to the passage of food is detected.

In diseases of the pharynx and organic lesions of the nervous system, dysphagia is usually combined with other subjective and objective symptoms that facilitate the recognition of the underlying disease. In hysterical neurosis, as well as in the early stages of some diseases of the esophagus (including tumors), dysphagia may be the only subjective manifestation of the disease, and distinguishing between functional dysphagia and dysphagia of an organic nature can present significant difficulties. It is usually taken into account that functional dysphagia is characterized by episodic occurrence or intermittent course and is provoked by swallowing not so much dense as irritating, for example hot or cold, food (neurotic dysphagia can be observed when swallowing liquid food and even water, but absent when swallowing dense food mass). The degree of functional dysphagia usually does not change over time. Organic is characterized by the absence of remissions and dependence on the density of food intake. Drinking water with food usually brings relief.

Dysphagia- a frequent symptom of damage to the esophagus and one of the few direct, alarming symptoms of gastroenteritis

Scheme 9. The relationship of learning objectives of this and other disciplines

Scheme 10. The relationship of learning objectives on this and previously studied topics

rology. In this regard, all patients with dysphagia should be carefully examined in order to establish the specific cause of its development. Among the modern instrumental methods that allow in most cases to establish the cause of dysphagia are radiography with a barium suspension, esophagogastroscopy with biopsy and cytological examination of the material taken, esophagotonometry, intraesophageal pH-metry, esophageal scintigraphy, esophageal endosonography. The given research methods

are listed in the order in which they should be administered to patients presenting for the first time for dysphagia.

Symptoms associated with dysphagia are of great diagnostic value. A pronounced decrease in body weight, often out of proportion to the severity of dysphagia, is characteristic of esophageal cancer. A hoarse voice that occurs against a background of pre-existing dysphagia may indicate involvement of the laryngeal recurrent nerve in the process when the esophageal cancer spreads beyond it. Hiccups may indicate cancer in the distal esophagus. Vomiting, combined with dysphagia and alleviating the discomfort of fullness behind the sternum during the passage of food through the esophagus, is characteristic of an organic lesion of the distal esophagus (cardioesophageal cancer, achalasia of the cardia, esophageal stricture, etc.). The volume of vomit depends on the level of obturation of the esophagus: the more distal it is, the more vomit.

Short transient dysphagia may be due to the inflammatory process. Its combination with painful swallowing (odynophagia) suggests the presence of esophagitis, possibly candidal or herpetic, occurring in cancer patients or patients receiving immunosuppressive therapy.

Dysphagia can develop in both benign and malignant neoplasms of the esophagus. Intraluminal tumors can be either epithelial (adenomas, papillomas) or non-epithelial (leiomyomas, fibromas, lipomas, hemangiomas, etc.). Intramural (intramural) tumors are always non-epithelial. Benign tumors of the esophagus (especially if they are small) in many cases are asymptomatic. Large tumors and ulcerated tumors cause dysphagia, chest pain, regurgitation, and may cause esophageal bleeding.

The leading complaint of patients with malignant tumors, in the general structure of which the main part (more than 95%) is occupied by squamous cell carcinoma and adenocarcinoma of the esophagus, is dysphagia. However, this symptom appears with a narrowing of more than 2/3 of the lumen of the esophagus, so it is not early. Complaints of patients can be focused on common symptoms: weakness, fatigue, decreased performance, progressive weight loss. In some cases, these symptoms are observed before local, indicating

for damage to the esophagus. With significant stenosis of the esophagus, regurgitation and esophageal vomiting (sometimes with streaks of blood) join, which, in turn, can cause aspiration complications. Ulceration of the tumor causes pain in the chest and odynophagia. Germination of the tumor in the trachea and large bronchi is manifested by a painful cough and stridor breathing. When an esophageal-bronchial or esophageal-tracheal fistula occurs, coughing occurs when eating. In such cases, aspiration pneumonia and lung abscesses often develop. With the germination of a tumor of the recurrent laryngeal nerve, hoarseness of the voice joins. The defeat of the sympathetic trunk causes the appearance on the affected side of Horner's syndrome (ptosis, miosis, enophthalmos), and the involvement of the phrenic nerve in the process is accompanied by a violation of the excursion of the diaphragm and the occurrence of hiccups. An objective examination of patients in the early stages of esophageal cancer often does not reveal any changes. In patients with advanced stages of the tumor, attention is drawn to the pale color of the skin, often with an earthy tint, bad breath due to tumor decay, swollen lymph nodes in the neck, and in some cases ascites (as a sign of metastatic liver damage).

decisive role in diagnostics neoplasms belongs to instrumental methods of examination. On x-ray examination, intraluminal benign tumors show a round filling defect with clear outlines and without disturbances in the peristalsis of the esophageal wall at the site of the tumor, and intramural tumors look like a marginal filling defect with smooth edges and preserved mucosal folds over the tumor. A malignant tumor with exophytic growth and decay with ulceration is detected by a filling defect with uneven, “corroded” edges. With endophytic (infiltrative) growth, a flat filling defect is determined, circularly narrowing the lumen of the esophagus. The wall of the esophagus over this area becomes rigid. Additionally, computed tomography and endosonography can be performed. An important method for diagnosing neoplasms of the esophagus is esophagogastroscopy with biopsy. With exophytic growth, a tuberous tumor is determined, protruding into the lumen of the esophagus, bleeding on contact. With endophytic growth, there is a rigidity of the esophageal wall at the site of the lesion, and with ulceration of the tumor, irregularly shaped ulcers

with bumpy, uneven edges. In cases where the tumor is located intramurally, and its benign nature is beyond doubt, biopsy is not recommended, as this causes the development of adhesions between the mucosa and the tumor and makes subsequent surgical excision of the tumor difficult.

Radiography is the primary, screening method, it must be performed after a sip of first a liquid, and then a thick suspension of barium, if necessary in a horizontal position.

Esophagogastroscopy with a mandatory examination of the cardiac part of the stomach is also performed for all patients in the absence of contraindications.

Tonometry is carried out without fail before intraesophageal pH-metry to determine the level of installation of the probes, it allows you to determine the presence and nature of motor disorders of the esophagus, measure pressure in the lower esophageal sphincter to exclude achalasia of the cardia.

Intraesophageal pH-metry is the most significant method in the modern diagnosis of GERD. The intraesophageal pH, which is normally 7.0, decreases with each episode of gastroesophageal reflux below 4.0. Their total frequency and duration are also calculated.

Esophageal scintigraphy is of limited use in practice, but it allows assessing the state of the motor function of the esophagus, the tone of the lower esophageal sphincter. Conduct a study with labeled technetium (99m Tc). Normally, about 90% of the maximum volume of swallowed standard food labeled with a radioactive isotope should be evacuated from the esophagus to the stomach within 10 s. An increase in this time, the so-called delayed esophageal clearance, indicates a decrease in the peristaltic activity of the esophageal wall and can be observed, for example, in patients with systemic scleroderma.

Endosonography makes it possible to judge the state of all layers of the esophageal wall and the surrounding mediastinal organs, helps to identify tumors of the esophagus (especially those located in the submucosal layer) and assess the state of regional lymph nodes, which is important when deciding on surgical treatment. The method is an ultrasound examination performed by inserting an ultrasound probe into the esophagus during esophagoscopy.

The diagnosis of a polyp of the esophagus is an indication for surgery to remove it because of the risk of malignancy and bleeding.

Malignancy of polyps (even small ones) is often observed. Surgical intervention is also indicated for intramural tumors due to possible complications - malignancy, compression of surrounding organs, and for cysts - their suppuration and perforation. An exception may be only small intramural tumors with confirmed benignness or in the case where surgical treatment poses a significant risk due to comorbidities. In such situations, dynamic observation is indicated.

Surgical intervention for polyps and intramural tumors is different. With polyps of small sizes on a thin, long stem, a tumor can be removed through an esophagoscope with a special loop with coagulation of the stem to prevent bleeding. Polyps on a wide base are excised, followed by strengthening the suture line with a flap of the diaphragm on the leg. The main principle of surgical treatment of benign intramural tumors and cysts of the esophagus is the use of organ-preserving operations, i.e. their enucleation. The tumor is almost always removed without damaging the esophageal mucosa. In case of accidental damage to the mucous membrane, the gap must be sutured with double-row sutures. Long-term results of operations are good.

Treatment esophageal cancer largely depends on the location of the tumor. Thus, cancer of the cervical and upper thoracic esophagus, located above the aortic arch, proceeds extremely unfavorably: it germinates early into the surrounding organs and metastasizes. Unsatisfactory results of operations forced surgeons to refuse resection of the esophagus in these patients in favor of radiation therapy. In the initial stages of cancer of these parts of the esophagus, radical surgery can and should be performed.

In some cases, radiation therapy allows you to transfer the tumor from doubtfully resectable to resectable. In case of cancer of the midthoracic esophagus, as a rule, extirpation of the esophagus is performed according to Dobromyslov-Torek. In some cases, in strong young people, a one-stage operation of the Suite type is acceptable with the imposition of a high esophageal-gastric anastomosis. In case of cancer of the lower thoracic esophagus, a resection of the esophagus is performed and an esophageal-gastric anastomosis is applied.

Postoperative mortality in single-stage operations is very high and reaches 30%. Currently, in cancer of the midthoracic region, most surgeons are inclined in favor of

a two-stage operation: first, this is extirpation of the esophagus according to Dobromyslov-Torek, and then (after 3-6 months), when the patient is strong enough, plastic surgery of the esophagus with a small or large intestine. Esophageal plasty in this case should be done in the simplest and safest way, i.e. presternal.

indications for surgery. When deciding on surgical treatment, it should be taken into account that surgery for esophageal cancer is extremely complex, traumatic and, despite the progress of surgery, anesthesiology and resuscitation, is accompanied by high mortality. Two concepts should be distinguished - operability and resectability. Operability refers to the ability to operate on a patient. Inoperable patients with esophageal cancer are for two reasons:

1) due to the prevalence of the lesion (presence of distant metastases, esophagotracheal fistula, etc.);

2) due to general contraindications to major surgery (advanced age of patients in combination with "senility", cardiopulmonary insufficiency, etc.).

Resectability is the ability to remove the tumor. The possibility or impossibility of its removal usually becomes clear only during the operation. Thus, the patient may be completely operable, but the tumor may be unresectable.

Situational task number 1

A 58-year-old patient was admitted to the clinic with complaints of a violation of swallowing and passage of food through the esophagus that arose 4 months ago. With difficulty passes and mushy food. Increased salivation, regurgitation are noted. Appetite saved. During the illness I lost 6 kg (Fig. 29).

Your preliminary diagnosis, examination plan and treatment tactics?

Situational task number 2

A 52-year-old patient was admitted with complaints of dysphagia. The disease has existed for several years. X-ray examination of the esophagus with barium suspension in the wall of the esophagus reveals a limited filling defect with smooth contours and unchanged mucous membrane (Fig. 30, a). Esophagoscopy confirmed

Rice. 29 (see also color insert)

Rice. 30 (see also color insert). X-ray of the esophagus (a) and a distant neoplasm (b) in a 52-year-old patient

submucosal tumor of the esophagus (Fig. 30, b). Biopsy is contraindicated due to possible damage to the mucous membrane, which further complicates surgical treatment and increases the duration of the hospital period.

What operation is indicated for this patient?

Test tasks

1. What methods of treatment for cancer of the middle third of the esophagus are considered radical:

1) Operation Dobromyslov-Torek;

2) extirpation of the esophagus with simultaneous esophagoplasty from the gastric tube or segment of the intestine;

4) radiation therapy;

5) chemotherapy.

2. What clinical signs are found in benign neoplasms of the esophagus:

1) dysphagia;

2) loss of body weight;

3) sensation of a foreign body in the esophagus;

4) heartburn;

5) aching pain in the epigastric region.

3. Benign neoplasms of the esophagus can be:

1) fibroids;

2) fibromas;

3) lipomas;

4) melanoma;

5) angiomas.

4. Early clinical manifestations of esophageal cancer are:

1) dysphagia;

2) loss of body weight;

3) retrosternal pain;

4) burning sensation when swallowing food;

5) lack of appetite.

5. Patient, 64 years old. Against the background of complete well-being 2 months ago, gradually increasing dysphagia, salivation, coughing for no apparent reason, a burning sensation behind the sternum when swallowing food, aching pain behind the sternum, especially at night, appeared. Appetite

not violated. Complete blood count without abnormalities. I lost 2-3 kg in 2 months.

Suggested diagnosis:

1) reflux esophagitis;

2) esophageal leiomyoma;

3) cardiospasm;

4) cancer of the esophagus;

5) Zenker's diverticulum of the esophagus.

6. Malignant tumors of the esophagus:

1) most often are adenocarcinomas;

2) more common in male patients;

3) often affect the upper third of the esophagus;

4) usually metastasize lymphogenously;

5) can be successfully treated with radiation therapy.

7. Esophageal carcinoma:

1) rarely keratinizing;

2) manifests itself in the form of progressive dysphagia;

3) usually affects the middle third of the esophagus;

4) more often develops in men;

5) rarely spreads hematogenously.

8. What research methods are most informative for the diagnosis of benign neoplasms of the esophagus:

1) x-ray of the esophagus with barium;

2) esophagomanometry;

3) esophagoscopy;

4) electrokymography;

5) sonography.

9. What method is used in the treatment of benign neoplasms of the esophagus:

1) extirpation of the esophagus;

2) enucleation of the tumor of the esophagus;

3) resection of a segment of the esophagus;

4) radiation therapy;

5) chemotherapy.

10. What research methods are used to confirm the diagnosis of esophageal cancer:

1) X-ray;

2) esophagomanometry;

3) esophagoscopy with biopsy;

4) mediastinoscopy with biopsy;

5) X-ray kymography.

11. Which of the following is characteristic of esophageal cancer?

1) transient dysphagia;

2) the peak incidence occurs at 40-50 years;

3) the diagnosis is established by X-ray of the esophagus with barium;

4) can be diagnosed endoscopically;

5) You may need to study the bronchi.

12. Esophageal carcinoma:

1) develops more often in men than in women;

2) most often leads to the development of adenocarcinoma;

3) usually manifested by dysphagia with a difficult to establish level of damage;

4) most often develops in the upper third of the esophagus;

5) associated with alcohol abuse and smoking.

13. Select the tumor most commonly found with Barrett's esophagus:

1) epidermoid cancer;

2) mucoepidermoid cancer;

3) small cell cancer;

4) adenocarcinoma;

5) adenoid cystic cancer.

Demo Material

1. Radiographs.

2.X-ray tomograms.

3. Endoscopic examination of the esophagus.

4. Bougienage of the esophagus.

5. Dilation of the esophagus.

6. Educational videos.

7. Visiting diagnostic rooms.