自发性食管破裂一例误诊分析并文献复习

Spontaneous Rupture of the Esophagus: Analysis of a Misdiagnosed Case and Literature Review

目的探讨自发性食管破裂的临床特点及误诊原因,并探讨防范措施。方法回顾性分析我院1例误诊为重症肺炎的自发性食管破裂患者的临床资料,并结合检索CNKI数据库命中的60篇文献共366例自发性食管破裂临床资料进行综述分析。结果 1本例因胸痛伴气促、发热1 d就诊,外院诊断重症肺炎。转我院后出现脓毒性休克,后于胸腔引流液中发现食物残渣,行胃镜检查于食管下端近贲门处见破口,确诊为自发性食管破裂、食管胸膜瘘致脓胸。予肠内营养、胃肠减压等综合治疗,病情好转出院。2文献检索的366例自发性食管破裂中误诊108例,误诊率29.5%,误诊为溃疡病穿孔30例,急性胸膜炎20例,急性胰腺炎18例,液气胸16例,急性胆囊炎9例,急性心肌梗死6例,心绞痛5例,肺栓塞2例,主动脉夹层、食管憩室各1例。经食管造影、胸腔引流液检查及手术探查等确诊;其中282例接受手术治疗,84例接受非手术保守治疗,共治愈310例,死亡56例。结论对于急性起病、剧烈呕吐后出现的胸部疼痛、上腹部疼痛者,应警惕食管破裂的可能,及时行胸部CT、食管造影、胸腔穿刺或引流口服亚甲蓝染色及胃镜等检查以确诊。

Objective To investigate the clinical characteristics and misdiagnosis causes of spontaneous rupture of the esophagus, and propose preventive measures. Methods We retrospectively analyzed clinical data of a patient with spontaneous rupture of the esophagus misdiagnosed as severe pneumonia, and reviewed 60 articles involving 366 cases of esophageal rupture from CNKI database. Results ① The patient was diagnosed with severe pneumonia outside the hospital for complaining of chest pain, shortness of breath and fever for one day, and was transferred to our hospital for further treatment. The symptoms of septic shock appeared soon after admission. Food debris was found in pleural fluid drainage. Gastroscopy was performed and the result showed that there was a rupture in lower esophagus near to cardiac, then the patient was diagnosed with spontaneous rupture of the esophagus and esophageal fistula induced pyothorax. After comprehensive treatments such as enteral nutrition and gastrointestinal decompression, the patient was discharged with improvement. ② In the 366 cases of spontaneous rupture of esophagus reported in the literature, 108 cases were misdiagnosed, and the misdiagnosis rate was 29. 5%. The misdiagnosed diseases included perforation of digestive tract ulcer （30 cases）, acute pleurisy （20 cases）, acute pancreatitis （18 cases）, hydropneumothorax （16 cases）, acute cholecystitis （9 cases）, acute myocardial infarction （6 cases）, angina pectoris （5 cases）, pulmonary embolism （2 cases）, aortic dissection （1 case） and esophageal diverticula （1 case） . All patients were eventually diagnosed by chest drainage, esophagogram and surgical exploration. Among these patients, 282 patients received surgical treatment and 84 patients received expectant treatment, and 310 recovered and 56 died. Conclusion Clinicians should pay attention to the possibility of esophageal rupture in the patients with acute chest pain and upper abdominal pain after heavy vomiting. Performing timely examinations of chest CT, esophagogram, gastroscope and thoracentesis or methylene blue staining are the keys to reduce misdiagnosis.