Esophageal cancer
Esophageal cancer is a malignant tumor of the squamous epithelium of the esophagus, and progressive dysphagia is its most typical clinical symptom. This disease is one of the common malignant tumors in human. China is the country with high incidence of esophageal cancer and also one of the countries with the highest mortality rate of this disease, with an average annual mortality rate of 14.59/100,000.
I. Clinical characteristics
(I) Early symptoms of esophageal cancer
1.Post-sternal and subxiphoid pain: Burning sensation, pinprick-like or pulling pain behind the sternum when swallowing, especially when swallowing rough, overheated or irritating food. The pain can be relieved by antispasmodic drugs and recurs intermittently. When the cancer invades nearby tissues or has penetrated, there may be severe and continuous pain. The site of pain is often not completely consistent with the site of esophageal lesion.
2. Food retention and foreign body sensation: When swallowing food or drinking water, there is the sensation of slow passage and retention of food, or the sensation of tightness behind the sternum or foreign body attached to the esophagus wall, which disappears after eating. The location of the symptoms is mostly consistent with the location of the lesion in the esophagus.
3.Choking sensation in the throat: the most common, mild choking sensation in the throat, sometimes light and sometimes heavy. It can disappear and recur on its own, does not affect eating, and can occur or worsen during mood swings.
4.Dryness and tightness in the throat: It is especially obvious when swallowing dry and rough food.
5.Other symptoms: there may be post-sternal stuffiness, back pain and belching, etc.
(II) Middle and late stage symptoms of esophageal cancer
1.Progressive dysphagia: It is the main symptom of most patients at the time of consultation, but it is the late manifestation of the disease. Because of the elasticity and expansion ability of esophageal wall, dysphagia only appears when about 2/3 of the circumference of esophagus is infiltrated by cancer. With the cancerous mass destroying the muscle wall, invading the circumference of esophagus and blocking the lumen, the lesioned esophagus loses elasticity and forms an irregular narrow channel, and the difficulty in swallowing becomes more and more serious, from not being able to swallow solid food to not being able to swallow liquid food. If the cancer is accompanied by inflammation, edema and spasm of esophageal wall, the difficulty in swallowing can be aggravated. The site of obstruction is consistent with the site of cancer obstruction.
2.Food reflux: Due to the dilatation and retention of the near segment of esophageal obstruction, food reflux can occur. The reflux contains mucus and mixed with the food, which can be bloody or can be seen as necrotic detached tissue.
3.Pain in pharynx: It is caused by cancer erosion, ulcer, external invasion or proximal segment with esophagitis, especially after eating hot or acidic food, the pain can involve neck, scapula and back. B. Other symptoms: chronic dehydration, malnutrition, emaciation and cachexia due to prolonged lack of food intake. There are enlarged left supraclavicular lymph nodes or other manifestations caused by the spread of cancer metastasis, such as hoarseness due to compression of the recurrent laryngeal nerve, pain due to bone metastasis, jaundice due to liver metastasis, etc. When the tumor invades adjacent organs and perforates, esophagobronchial fistula, mediastinal abscess, pneumonia, lung abscess and hemorrhage from aortic perforation may occur, leading to death.
II. Laboratory and other tests
(A) Esophageal mucosal exfoliative cell examination
A double-lumen plastic tubing line sleeve mesh balloon cell collector is swallowed into the esophagus, and the balloon is inflated and expanded after passing through the lesion, and then the balloon is slowly pulled out. The positive rate can reach more than 90%, and some early cases can often be detected. It is an important method for mass screening of esophageal cancer.
(II) X-ray examination of esophagus
The signs of early esophageal cancer X-ray barium meal imaging include: thickened mucosal folds, tortuous interruptions like dashed lines, or burr-like esophageal edges; small filling defects; small ulcerative niches; limited wall stiffness or barium retention. In intermediate and advanced cases, irregular narrowing of the lumen at the lesion, filling defect, loss of peristalsis of the wall, mucosal disorder, soft tissue shadow and the paradoxical phenomenon of a huge filling defect of the intraluminal type with widening of the lumen, with mild to moderate dilatation and barium retention at its proximal end are seen.
(C) CT scan examination of esophagus
It can clearly show the relationship between the esophagus and the adjacent mediastinal organs. CT scan can fully reveal the size of esophageal cancer lesions, the extent and degree of tumor invasion, which can help to determine the surgical method, target area of radiotherapy and radiotherapy plan. However, CT scan is difficult to detect early esophageal cancer.
(IV) Endoscopy
It can directly observe the morphology of the lesion and do biopsy under direct vision to determine the diagnosis. Biopsy can also be combined with biopsy staining method to improve the detection rate. With toluidine blue staining, esophageal mucosa is not colored, but cancerous tissue can be stained blue; with Lugol iodine solution, normal squamous cells are brown because of glycogen content, while diseased mucosa is not colored.
Treatment of esophageal cancer
The key to cure of this disease lies in the early diagnosis of esophageal cancer. At present, the treatment methods with certain efficacy are surgery and radiotherapy.
(I) Surgical treatment
The surgical resection rate of esophageal cancer in China has reached 80%-90%, and the survival rate of 5 years after surgery has reached more than 30%, while early resection can often achieve curative effect. The efficacy of surgery is related to the location, length and extent of cancer.
(II) Radiation therapy
Radiotherapy is mainly applied to upper esophageal cancer which is difficult to be operated and middle and lower esophageal cancer which cannot be resected. The appropriate dose of 60Co treatment is 30-40Gy (3000-4000rad). Radiotherapy before surgery can shrink the cancer mass and improve the resection rate and survival rate.
(C) Chemotherapy
It is generally used after resection of esophageal cancer. The effect of chemotherapy alone is very poor. In order to improve the efficacy, the combination of cisplatin plus pinyamycin (or bleomycin), fluorouracil (5-fluorouracil), methotrexate, vincristine (vincristine amide) or mitomycin in duplex or quadruplex, etc., has been successively used in clinical practice. Combination chemotherapy has improved efficacy over single agent, but the overall chemotherapy status is unsatisfactory.
(iv) Endoscopic esophageal stenting
Endoscopic esophageal stenting is a non-invasive palliative treatment for cancerous esophageal strictures by placing an internal support tube under direct endoscopic view, which can relieve obstruction and prolong survival.
Esophageal smooth muscle tumor
I. Clinical manifestations
About half of the patients with smooth muscle tumor have no symptoms at all, and they are found by chest X-ray or gastrointestinal imaging due to other diseases. The most common symptom is mild dysphagia, which rarely affects normal diet. Even if the tumor is quite large, the obstructive symptoms are not severe because of its slow development. This is important in the differential diagnosis, which is not quite the same as the short-term progressive dysphagia caused by esophageal cancer. The severity of feeding obstruction may be intermittent and not exactly parallel to the size and location of the tumor, but mainly depends on the growth of the tumor around the lumen, and is also related to the mucosal edema and erosion on the surface of the tumor and psychological factors.
A small percentage of patients complain of pain, the location of which is variable and may be vague pain behind the sternum, chest, back and upper abdomen, but rarely severe. It can occur alone or in combination with other symptoms. About 1/3 of patients have digestive disorders, including heartburn, acid reflux, abdominal distension, postprandial discomfort and dyspepsia. Individual patients have symptoms of upper gastrointestinal bleeding such as vomiting blood and black stool, which may be caused by mucosal erosion and ulceration on the surface of tumor.
Diagnosis
1.X-ray examination: X-ray barium esophagus examination is the main diagnostic method of this disease, combined with clinical manifestations, the diagnosis can often be confirmed in one imaging.
2.Fiber esophagoscopy: Most of smooth muscle tumors can be diagnosed by barium esophagus meal, together with fiber esophagoscopy (in fact, fiber gastroscopy is often used), the accuracy of examination can reach more than 90%, and the location, size, number and shape of the tumor can be understood. On microscopic examination, we can see the mass protruding in the esophageal cavity, the surface mucosa is intact, smooth and spreading, the folds disappear, and the edges of the myxoma are faintly visible, and when swallowing, the mass can be seen to move up and down lightly, and there are not many lumen narrowing.
3.CT and magnetic resonance imaging (MRI) examination: CT can understand the expansion of the mass outside the canal and the exact location, which can help the design of surgical plan and incision.
III. Treatment measures
Surgical treatment: Although smooth muscle tumor is a benign disease, it has the possibility of potential malignant transformation. Therefore, except for older patients, smaller tumors, asymptomatic patients, patients with poor cardiopulmonary function who cannot tolerate surgery or patients who refuse surgery, surgical treatment is recommended once the diagnosis is clear.
Cardia failure
I. Clinical manifestations
Cardia spasm is mostly seen in young adults, with a slow onset and a long course. The most common early symptoms are dysphagia, retrosternal pain and obstruction, sometimes solid food is easier to swallow than liquid, and warm food is easier to swallow than cold food. The symptoms of dysphagia have periods of remission, intermittent episodes, and are sometimes mild and severe. Mental and emotional changes can affect the symptoms, and the symptoms are aggravated by mental stress or emotional excitement. These characteristics can be used to distinguish esophageal cancer from dysphagia due to esophageal scar stenosis. As the disease progresses, the remission period gradually disappears and the dysphagia is persistent. As food is retained in the esophagus, it often presents with vomiting, which is undigested food and does not contain gastric acid. If the food is retained in the esophagus for a long time and then vomited, it has a putrid odor. Food spillage into the respiratory tract can lead to aspiration pneumonia or lung abscess.
Diagnosis
Barium meal X-ray examination of the esophagus shows that the barium is retained in the cardia, and the lower part of the esophagus shows a bird’s mouth narrowing with smooth edges, and the barium enters the stomach slowly in a thin stream. The lumen of the lower and middle esophagus is enlarged, and in severe cases, the lumen of the esophagus is highly thickened and extended and tortuous in an “S” shape.
Treatment
Patients with severe symptoms are usually treated by surgery, which is effective.
Esophageal hiatal hernia
The clinical manifestations of patients with paraesophageal hernia vary depending on the contents of the hernia, but the common clinical features are premature infection with fullness during feeding, vomiting after eating a lot, epigastric discomfort, dysphagia, and chest gurgling. Difficulty in swallowing is caused by the herniated viscus pressing on the esophagus from the outside. The herniated viscus squeezing the lung and occupying a part of the thoracic cavity can cause coughing and dyspnea after meals. If complicated by obstruction, stenosis, necrosis or perforation of the hernia contents, the patient has symptoms of shock and gastrointestinal obstruction, and severe cases are often fatal.
I. Diagnosis
X-ray barium meal examination and CT examination can be diagnosed.
Treatment
Once diagnosed, esophageal hiatal hernia usually requires surgery. Because it may cause entrapment, strangulation of intestinal tube and other contents and inactivation, Gu should be operated early.