Diseases of the esophagus. Chest pain in diseases of the esophagus

With megaoesophagus, typical swallowing difficulties leading to the correct diagnosis (the patient has a feeling of pressure, solid food stuck in the throat, the patient gags) sometimes does not stand in the foreground, and vague pulling pains in the chest area at first is sometimes difficult to interpret correctly. The true picture in most cases is accurately determined by X-ray examination of the esophagus. 

Cancer of the esophagus in many cases is usually recognized relatively early in the presence of a typical history (difficulty swallowing, feeling of pressure and constriction, stuck food lump at a certain height). In less typical cases, however, when pain radiating to the region of the heart comes to the fore, with a feeling of fear or cough, the diagnosis becomes more difficult. Of 35 patients at the Zurich Surgical Clinic, 11% had no dysphagia at all (Vultejus). If you suspect esophageal cancer, the doctor should remember that it is mainly alcoholics (90%) and elderly men (more often in the 7th decade of life) who fall ill. 

Yet dysphagia (sticking of dense pieces of food and a foreign body sensation in the esophagus) with esophageal cancer is absolutely the leading symptom. Dysphagia may be unstable at first, and sometimes disappear.  

X-ray examination and esophagoscopy make it possible to diagnose with great accuracy. At the onset of the disease, the rigidity of the esophageal wall, filling defects and ulceration are poorly expressed and can escape the radiologist. Therefore, in all unclear cases of dysphagia, esophagoscopy is necessary.   

Only in later stages, as a result of the involvement of neighboring organs, hoarseness and aphonia (damage to n. Recurrens), Horner’s syndrome (damage to the sympathetic nerve), shortness of breath (compression of the trachea) are added here .    

A diverticulum of the esophagus under some conditions also gives symptoms, which are initially mistaken for heart damage. A feeling of tightness, a feeling of dryness in the cervical esophagus, cough, difficulty swallowing can be misinterpreted. Experience shows that the correct diagnosis of esophageal diverticulum is made on average only 4% of the year after the onset of the first symptoms. Food regurgitation (which, however, is often observed only in a later stage) and X-ray findings allow a correct diagnosis of a pulsatile diverticulum to be arrived at. 

It is also important to know that men get sick 3 times more often than women , that the disease is very rare in people under 40 years old and in 82% it is observed only in the 7th decade of life. 

Traction diverticula , which are less than pulsatile, are located more in the middle part of the esophagus and are much less often accompanied by food regurgitation, but rather escape during X-ray examination. Therefore, burning pains behind the sternum with this form of the disease are often misinterpreted.

Esophagitis appears to be much more common than it used to be. In addition to changes in the mucous membrane of the esophagus in states of vitamin deficiency, reflux-oesophagitis, the throwing of gastric juice into the esophagus, plays the greatest role in the origin of esophagitis; it is often observed in esophageal-gastric hernia of the esophageal opening of the diaphragm as a result of disturbed tone in gastric and duodenal ulcers, as well as in biliary dyskinesia (rarely) and after resection of the esophagus. The sphincter function can also be impaired in case of abnormalities in the cardia area. In severe cases, a peptic ulcer of the esophagus appears at the site of esophagitis. With esophagitis in the distal esophagus and peptic ulcer of the esophagus, more or less severe pain behind the xiphoid process is observed, the dependence of which on the act of swallowing in most cases is clearly expressed, but they may not be associated with food intake. As with ulcers of other localizations, peptic ulcer of the esophagus in V4 cases is complicated by posthemorrhagic anemia. For the diagnosis, changes are also valuable, established by X-ray and esophagoscopic (often only stenosis), but they are not necessary. 

Pain emanating from the stomach , especially with a hernia of the hiatus and with a weakening of the tone of the diaphragm (relaxatio diaphragmatica) is felt in the chest area. They are often the expression of mucosal ulceration in the parts of the esophagus above the diaphragm. 

The symptomatology of hiatal hernia has been well developed in recent years. Anatomically, 3 types can be distinguished: type I – a very short esophagus, type II – hernia is located near the esophagus (paraesophageal hernia), type III – a hernia without changes in the esophagus. Clinically, however, this radiological distinction is not very important. For a hernia of the esophageal opening of the diaphragm, it can be considered characteristic: 

a) Standing in the foreground pain in the epigastric region, felt behind the xiphoid process or also radiating to the back, to the upper chest, to the shoulders and arms. It is especially difficult to correctly distinguish these complaints from those observed in diseases of the heart and lungs, which may be discussed here.
b) The dependence on the position of the body is almost always expressed: the pain intensifies in the supine position (for example, in the evening before bedtime) and disappears in the sitting position and when walking.
c) In the presence of reflux oesophagitis, pain occurs already while eating or swallowing. Further clinical symptoms: belching (common), vomiting (rare), post-hemorrhagic anemia, ECG signs of myocardial damage, and recurrent obscure thrombophlebitis (Wegmann). The X-ray picture may not reveal anything if the hiatal hernia is not specifically looked for using special techniques (Hafter). For an X-ray diagnosis, it is imperative to identify folds of the mucous membrane in the formations located above the diaphragm. Only the picture of the gastric mucosa in the hiatal hernia makes it possible to distinguish it from the physiological ampulla oesophagi, which has a spherical shape and smooth walls. If signs of a hiatal hernia first appear in old age, the doctor can be content with this diagnosis only after careful exclusion of other diseases that may be responsible for the symptoms in the patient in one way or another. The wasting caused by cancer can cause the hiatus to widen and empty the stomach. The combination of a hiatal hernia with cholelithiasis (often a more important cause for complaints than a hernia) and diverticulosis constitutes Saint’s syndrome.

Cardiospasm . The main symptom of cardiospasm, along with difficulty in swallowing and belching, are chest pain. Cardiospasm is twice as common in women as in men. Often there are also other symptoms of increased excitability of the autonomic nervous system. The radiograph shows a spastic contraction of the lowermost segment of the esophagus. The barium mass often does not pass into the stomach for a long time, the esophagus is dilated and spindle-shaped downwardly narrowed.

Retrosternal pain with intoxication . Severe pain is noted in many patients with thallium poisoning.

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