Symptoms of esophageal foreign bodies

Clinical symptoms vary greatly, from asymptomatic carriage to a severe condition, depending on the type, level of fixation, and time of presence of the foreign body in the esophagus, as well as the nature of the complications that have developed. The most pronounced disorders are caused by foreign bodies in the cervical esophagus. These include a forced position of the head tilted forward and downward; refusal to eat; sharp pain when swallowing in the area of the jugular notch; hypersalivation; retention of saliva in the pyriform sinuses (Jackson's symptom); accumulation of foamy mucus in the pharynx and difficulty swallowing solid food; repeated vomiting that does not bring relief; slow, quiet speech; pain upon palpation in the suprasternal region and when displacing the soft tissues of the neck; an admixture of blood in saliva and vomit with pointed foreign bodies. Large foreign bodies of the first physiological stenosis of the esophagus are accompanied by symptoms of respiratory distress, and prolonged presence of a foreign body in the cervical esophagus in young children leads to the development of bronchopulmonary pathology.

Signs of foreign body getting stuck in the esophagus depend on its shape and size, as well as the level of wedging. Foreign bodies with a smooth surface but significant size do not cause severe acute pain, but are accompanied by a feeling of distension in the chest and dull pain. Pointed foreign bodies that have wedged into the wall of the esophagus, injuring it, cause acute unbearable pain, which intensifies with movements in that part of the neck or body at the level of which the wedging occurred.

All symptoms of foreign bodies in the esophagus are divided into immediate, early and late. The first are caused by the primary reaction to the introduction or wedging of foreign bodies and their mechanical effect on the esophageal wall, the second appear after the primary reaction and progress during the subsequent acute clinical period; the third are detected when complications arise (perforation, infection). Painful sensations and other signs provoked by them are defined as pain syndrome in foreign bodies of the esophagus, which evolves together with the development of the entire clinical picture of foreign bodies in the esophagus.

Immediate symptoms, as noted above, are manifested in the occurrence of a sensation of pain that occurs during the swallowing of foreign bodies, which rapidly increases and is accompanied by salivation. These pains, depending on their nature and intensity, may indicate foreign bodies getting stuck, damage to the mucous membrane, perforation of the esophageal wall or its rupture. Sometimes aphonia also occurs, caused by repercussion (reflex).

Early symptoms

Early symptoms are characterized by the establishment of qualitative signs of pain syndrome. Thus, the intensity of pain may indicate the level of penetration of foreign bodies in this period: the upper sections of the esophagus are more sensitive, the lower sections are less sensitive to painful stimuli, therefore the most pronounced pain syndrome occurs when foreign bodies are wedged into the upper sections of the esophagus. Pain may be constant or variable. Constant pain indicates the penetration of foreign bodies into the wall of the esophagus with its damage or even perforation. Variable pain in most cases indicates only the wedging of foreign bodies into the lumen of the esophagus and intensifies only with movements in the cervical spine and thoracic spine. Pain sensations can be localized (in the neck, behind the sternum or in the interscapular space), diffuse, radiating. In children, as well as in adults, pain may be absent, especially with smooth-walled round foreign bodies. If foreign bodies are introduced into the bifurcation area of the trachea, the pain is localized retrosternally in the depth of the chest cavity or prevertebrally at the level of the II - IV thoracic vertebrae. The introduction of foreign bodies into the lower sections of the esophagus causes a feeling of pressure deep in the chest and pain in the heart and epigastric region. Sometimes the pain radiates to the back, lower back and sacral region. Quite often, the patient's complaints of pain in various locations are caused only by trace effects left by foreign bodies on the wall of the esophagus (most often these are abrasions or even deeper injuries), while the foreign body itself has slipped into the stomach.

Along with pain, dysphagia occurs, which is especially pronounced for solid food and may be moderate or absent when taking liquid food or water. The absence of dysphagia does not exclude the presence of foreign bodies. Dysphagia in the presence of foreign bodies is almost always accompanied by vomiting or regurgitation. During the period of early symptoms, especially when drinking is impossible, victims experience severe thirst, they begin to lose weight not only due to failure to replenish the body's water resource, but also due to alimentary insufficiency.

If a foreign body is located in the upper part of the esophagus, its volume can push the larynx forward, which makes the lower part of the pharynx look wider (Denmayer's symptom). Pressure on the larynx from the front with this localization of foreign bodies causes the appearance or increase of pain (Schlittler's symptom). The accumulation of saliva and mucus in the pyriform fossae (Jackson's symptom) indicates complete or partial obstruction of the esophagus, which is observed not only in the presence of foreign bodies in it, but also in tumors or burns.

Respiratory failure occurs when a foreign body gets stuck at the entrance to the esophagus or at the level of the larynx. These failures may be caused by mechanical or reflex action of foreign bodies, leading to compression of the larynx and its spasm. Sometimes these respiratory failures are so severe that an emergency tracheotomy has to be performed. Respiratory failure may also be caused by compression of the trachea when foreign bodies are wedged before the bifurcation. If dyspnea is present when foreign bodies are wedged below the bifurcation, it is caused by the resulting inflammatory edema of the tissue surrounding the trachea or one of the main bronchi. Particularly severe forms of respiratory failure occur with inflammatory edema in the area of the entrance to the larynx with the involvement of the arytenoid cartilages and aryepiglottic folds in this process. Compression of the larynx and trachea may be accompanied by noisy (hissing, whistling, stridor) breathing, uncontrollable cough. Since dyspnea also depends on the position of the head when foreign bodies are wedged at the level of the larynx, the patient puts it in a forced position, most often this is a forward bend and slightly to the side. When foreign bodies are wedged in the thoracic spine, the patient takes a forced position of bending the body forward, in which the pain is somewhat reduced due to a decrease in the tension of the esophagus.

At the end of the early symptom period, the triad of signs described by Killian (Killian's triad) may appear:

1. a sharp increase in pain and its spread below the level at which it was noted at the moment of wedging of foreign bodies;
2. infiltrate in the soft tissues of the neck and in the area of the cricoid cartilage;
3. a sharp increase in temperature with chills.

This triad indicates the spread of the inflammatory process to the tissue surrounding the esophagus. Secondary symptoms may appear immediately after the primary ones, but sometimes they appear after a certain "light" period, which may last for more than one day. During this period, dysphagia may be minimal and manifest itself only when eating solid food or be absent altogether.

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Late symptoms

Late symptoms follow the period of early symptoms and are manifested first by signs of local, then diffuse inflammation of the esophagus and periesophageal tissue. In case of esophageal perforation, signs of this inflammation usually appear simultaneously with early symptoms.

Esophageal perforations may be primary or secondary. The former occur much less frequently than perforations caused by unsuccessful manipulations during removal of foreign bodies or their blind pushing into the stomach. The latter occur as a result of the formation of a pressure ulcer and ulceration of the esophageal wall, followed by a submucous abscess, melting of the muscle layer and penetration of the sharp part of the foreign body into the periesophageal space.

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

Signs of perforation are characterized by some specific features depending on the level of damage to the esophagus.

Perforations at the level of the cervical esophagus in fresh cases are initially characterized by a benign course. However, they are early complicated by an abscess in the area of the paraesophageal tissue with its spread outward or into the esophageal space. In the first case, this process is manifested by the appearance of a swelling in the area of the carotid triangle, smoothing the relief of the neck in this area. Movements in the neck become very sensitive and painful. The larynx shifts to the healthy side. A pathognomonic symptom of esophageal perforation in the cervical region is subcutaneous emphysema on the neck on the side of the perforation, which occurs when air is swallowed (empty swallow) and spreads to the face and anterior chest surface. Gases produced by anaerobic microorganisms may be added to the atmospheric air.

In the second case, perforation of the esophageal wall leads to rapid development of phlegmon of the neck, spreading freely downwards to the posterior mediastinum. Pus from the retroesophageal space can also descend along the vascular-nerve bundle into the suprasternal space and anterior mediastinum. Of the clinical symptoms, with significant spread of the process, respiratory distress occurs very early. Purulent processes in the spaces between the esophagus, trachea and prevertebral fascia most often originate from the retropharyngeal lymph nodes, where the infection gets with infected foreign bodies of the upper esophagus. These processes cause a severe clinical picture mainly due to respiratory distress and swallowing.

Without timely surgical intervention, which in the vast majority of cases against the background of massive antibiotic therapy predetermines a favorable outcome, the purulent-inflammatory process quickly evolves with spread to the mediastinum, the breakthrough of pus into which causes a temporary improvement in the patient's condition (lowering of body temperature, decrease in pain intensity, disappearance of swelling in the neck). This false "recovery" is a formidable sign of impending mediastinitis, the prognosis of which is extremely serious.

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

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

When a foreign body is fixed in the thoracic part of the esophagus, the symptoms are less pronounced. Pain in the sternum is characteristic, increasing with attempts to swallow and radiating to the interscapular region and arm; vomiting becomes less frequent: salivation is less pronounced, since there is an opportunity for its accumulation in the upper third of the esophagus.

Foreign bodies in the diaphragmatic part of the esophagus cause girdle pain in the epigastric region. Salivation is uncommon. Vomiting occurs when trying to swallow solid food. With partial obstruction of the lumen of the esophagus, liquid food can pass into the stomach.

Clinical symptoms are most pronounced during the first day after swallowing a foreign body. On the second day, the pain subsides as a result of a decrease in the reflex spasm of the esophagus. Patients try to avoid coarse food, creating a false impression of well-being. After 2 days, the condition deteriorates sharply due to the development of esophagitis and periesophageal complications.

In infants and young children, clinical symptoms are atypical. Initial symptoms quickly pass, and the resulting stenotic phenomena are regarded as manifestations of an acute respiratory disease. Foreign bodies in newborns cause anxiety in the child and vomiting during feeding, salivation, respiratory failure, early development of aspiration pneumonia and inflammatory changes in the wall of the esophagus and periesophageal tissue with hyperthermia, toxicosis, exsicosis, parenteral dyspepsia.

Complications

Complications develop in 10-17% of cases of foreign bodies in the esophagus, especially often in childhood. The younger the child, the greater the likelihood of complications, the earlier they appear and the more severe they are.

Esophagitis is diagnosed within a few hours after swallowing a foreign body, it can be catarrhal, purulent, erosive-fibrinous (this form is accompanied by pain when turning the head and palpating the neck, nausea, vomiting with blood, forced position of the head, temperature reaction). There are unpleasant sensations behind the sternum, moderate pain when swallowing, slight salivation. During endoscopy, an eroded surface with areas of dirty-gray necrosis and excessive growth of granulations are found at the site of localization of the foreign body. During fluoroscopy, an "air bubble symptom" and an "air arrow symptom" are determined in the lumen of the esophagus at the level of the mucous membrane injury.

The development of periesophagitis is accompanied by deterioration of the general condition, increased pain behind the sternum, increased body temperature, the appearance of soft tissue edema and subcutaneous emphysema of the neck, a significant increase in the tone of the cervical muscles, a forced position of the head, submandibular, retropharyngeal and cervical lymphadenitis. The development of respiratory stenotic disorders is possible due to reactive edema of the outer ring and subglottic cavity of the larynx, pneumonia. X-ray examination reveals an increasing expansion of the retrotracheal space with air bubbles in the paraesophageal tissue, straightening of the physiological lordosis, and anterior displacement of the air column of the larynx and trachea - the symptom of soft tissues of Stuss; straightening of the cervical esophagus due to severe pain - the symptom of G.M. Zemtsov.

In case of abscess of the periesophageal tissue, a horizontal fluid level and multiple air bubbles in the periesophageal tissues are visible.

Mediastinitis often develops with penetrating and large impacted foreign bodies due to perforation and development of pressure ulcers of the esophageal wall. Symptoms of purulent intoxication increase, the condition deteriorates sharply, hyperthermia is noted. The pain intensifies and descends lower as a result of descending mediastinitis. A forced body position (semi-sitting or lying on the side) with legs drawn up to the stomach is typical. Breathing is difficult, groans. The skin becomes very pale, pain intensifies when talking and breathing deeply. Mediastinitis is most severe with perforation of the lower third of the thoracic esophagus.

Other complications of foreign bodies in the esophagus include phlegmonous periesophagitis with necrosis, gangrene of the esophageal wall, pleurisy, pneumothorax, lung abscess, sepsis, fibrinous-purulent pericarditis, peritracheal abscess with pus rupture into adjacent tissues, damage to the lower laryngeal nerve, IX-XII cranial nerves and the risk of erosive bleeding from large vessels and the mediastinum.

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