Congenital stricture of the esophagus may be single or multiple, and may be thin and weblike, or it may extend over a third or more of the length of the esophagus. It may not become manifest until solids are added to the child's diet; often not for many months. The lodgment of an unusually large bolus of unmasticated food may set up an esophagitis the swelling of which may completely close the lumen of the congenitally narrow esophagus. It is not uncommon to meet with cases of adults who have "never swallowed as well as other people," and in whom cicatricial and spasmodic stenosis can be excluded by esophagoscopy, which demonstrates an obvious narrowing of the esophageal lumen. These cases are doubtless congenital.
Webs in the upper third of the esophagus are best determined by the passage of a large esophagoscope which puts the esophagus on the stretch. The webs may be broken by the insertion of a closed alligator forceps, which is then withdrawn with opened blades. Better still is the dilator shown in Fig. 26. This retrograde dilatation is relatively safe. A silk-woven esophagoscopic bougie or the metallic tracheal bougie may be used, with proper caution. Subsequent dilatation for a few times will be required to prevent a reproduction of the stenosis.
Treatment of Esophageal Anomalies.—Gastrostomy is required in the imperforate cases. Esophagoscopic bouginage is very successful in the cure of all cases of congenital stenosis. Any sort of lumen can be enlarged so any well masticated food can be swallowed. Careful esophagoscopic work with the bougies (Fig. 40) will ultimately cure with little or no risk of mortality. Any form of rapid dilatation is dangerous. Congenital stenosis, if not an absolute atresia, yields more readily to esophagoscopic bouginage than cicatricial stenosis.
RUPTURE AND TRAUMA OF THE ESOPHAGUS
These may be spontaneous or may ensue from the passage of an instrument, or foreign body, or of both combined, as exemplified in the blind attempts to remove a foreign body or to push it downwards. Digestion of the esophagus and perforation may result from the stagnation of regurgitated gastric juice therein. This condition sometimes occurs in profound toxic and debilitated states. Rupture of the thoracic esophagus produces profound shock, fever, mediastinal emphysema, and rapid sinking. Pneumothorax and empyema follow perforation into the pleural cavity. Rupture of the cervical esophagus is usually followed by cervical emphysema and cervical abscess, both of which often burrow into the mediastinum along the fascial layers of the neck. Lesser degrees of trauma produce esophagitis usually accompanied by fever and painful and difficult swallowing.
The treatment of traumatic esophagitis consists in rest in bed, sterile liquid food, and the administration of bismuth subnitrate (about one gramme in an adult), dry on the tongue every 4 hours. Rupture of the esophagus requires immediate gastrostomy to put the esophagus at rest and supply necessary alimentation. Thoracotomy for drainage is required when the pleural cavity has been involved, not only for pleural secretions, but for the constant and copious esophageal leakage. It is not ordinarily realized how much normal salivary drainage passes down the esophagus. The customary treatment of shock is to be applied. No attempt should be made to remove a foreign body until the traumatic lesions have healed. This may require a number of weeks. Decision as to when to remove the intruder is determined by esophagoscopic inspection.
Subcutaneous emphysema does not require puncture unless gaseous, or unless pus forms. In the latter event free external drainage becomes imperative.
ACUTE ESOPHAGITIS
This is usually of traumatic or cauterant origin. If severe or extensive, all the symptoms described under "Rupture of the Esophagus" may be present. The endoscopic appearances are unmistakable to anyone familiar with the appearance of mucosal inflammations. The pale, bluish pink color of the normal mucosa is replaced by a deep-red velvety swollen appearance in which individual vessels are invisible. After exudation of serum into the tissues, the color may be paler and in some instances a typical edema may be seen. This may diminish the lumen temporarily. Folds of swollen mucosa crowd into the lumen if the inflammation is intense. These folds are sometimes demonstrable in the roentgenogram by the bismuth or barium in the creases between which the prominence of the folds show as islands as beautifully demonstrated by David R. Bowen in one of the author's cases. If the inflammation is due to corrosives, a grayish exudate may be visible early, sloughs later.