Certain cases prove very obstinate of cure, and require esophageal lavage for the esophagitis, and feedings through the stomach tube to increase nutrition and to dilate the contracted stomach. Gastrostomy for feeding rarely becomes necessary, for a stomach tube can always be placed with the esophagoscope if it will not pass otherwise. Retrograde dilatation with the fingers through a gastrostomy opening has been done, but seems hardly warranted in view of the excellent results obtainable from above. Instructions should be given concerning the proper mastication of food, and during treatment the frequent partaking of small quantities of liquid foods is recommended. Liquids and foods should be neither hot nor cold. The neurologist should be consulted in cases deemed neurotic.
[96a.-Functional hiatal stenosis. Cramp of the diaphragmatic pinchcock (so-called cardiospasm).]
Endocrine imbalance should be investigated and treated, as urged by
MacNab.
Esophageal antiperistalsis is the name given by the author to a heretofore undescribed disease associated with regurgitation of food from the esophagus, the food not having reached the stomach. It may be continuous or paroxysmal and may be of so serious a degree as to threaten starvation. The best treatment in severe cases is gastrostomy to put the esophagus at rest. Milder cases get well under liquid diet, rest in bed, endocrine therapy, cure of associated abdominal disease, etcetera.
[251] CHAPTER XXXII—DISEASES OF THE ESOPHAGUS (Continued)
CICATRICIAL STENOSIS OF THE ESOPHAGUS
Etiology.—The accidental swallowing of caustic alkali in solutions of lye or proprietary washing and cleansing powders, is the most frequent cause of cicatricial stenosis. Commercial lye preparations are about 95 per cent sodium hydroxide. The cleansing and washing powders contain from eight to fifty per cent of caustic alkali, usually soda ash, and are sold by grocers everywhere. The labels on their containers not only give no warning of the dangerous nature of the contents nor antidotal advice, but have such directly misleading statements as : "Will not injure the most delicate fabric," "Will not injure the hands," etc. Utensils used to measure or dissolve the powders are afterward used for drinking, without rinsing, and thus the residue of the powder remaining is swallowed in strong solution. At other times solutions of lye are drunk in mistake for water, coffee, or wine. These entirely preventable accidents would be rare if they were as conspicuously labelled "Poison" as is required by law in the case of these and any other poisons, when sold by druggists. The necessity for such labelling is even greater with the lye preparations because they go into the kitchen, whereas the drugs go to the medicine shelf, out of the reach of children. "Household ammonia," "salts of tartar" (potassium carbonate), "washing soda" (sodium carbonate), mercuric chloride, and strong acids are also, though less frequently, the cause of cicatricial esophageal stricture. Tuberculosis, lues, scarlet fever, diphtheria, enteric fever and pyogenic conditions may produce ulceration followed by cicatrices of the esophagus. Spasmodic stenosis with its consequent esophagitis and erosions, and, later, secondary pyogenic infection, may result in serious cicatrices. Peptic ulcer of the lower esophagus may be a cause. The prolonged sojourn of a foreign body is likely to result in cicatricial narrowing.
[FIG. 97.—Schematic illustration of a series of eccentric strictures with interstrictural sacculations, in the esophagus of a boy aged four years. The strictures were divulsed seriatim from above downward with the divulsor, the esophageal wall, D, being moved sidewise to the position of the dotted line by means of a small esophagoscope inserted through the upper stricture, A, after divulsion of the latter.]
Location of Cicatricial Esophageal Strictures.—The strictures are often multiple and their lumina are rarely either central or concentric (Fig. 97). In order of frequency the sites of cicatricial stenosis are: 1. At the crossing of the left bronchus; 2. In the region of the cricopharyngeus; 3. At the hiatal level. Stricture at the cardia has rarely been encountered in the Bronchoscopic Clinic. Stenosis of the pylorus has been noted, but is rare.
Prognosis.—Spontaneous recovery from cicatricial stenosis probably never occurs, and the mortality of untreated small lumen strictures is very high. Blind methods of dilatation are almost certain to result in death from perforation of the esophageal wall, because some pressure is necessary to dilate a stricture, and the point of the bougie, not being under guidance of the eye, is certain at sometime or other to be engaged in a pocket instead of in the stricture. Pressure then results in perforation of the bottom of the pocket (Fig. 98). This accident is contributed to by dilatation with the wrinkled, scarred floor which usually develops above the stricture. Rapid divulsion and internal esophagotomy are mechanically very easily and accurately done through the esophagoscope, and would yield a few prompt cures; but the mortality would be very high. Under certain circumstances, to be explained below, gentle divulsion of the proximal one of a series of strictures has to be done. With proper precautions and a gentle hand, the risk is slight. Under esophagoscopic bouginage the prognosis is favorable as to ultimate cure, the duration of the treatment varying with the number of strictures, the tightness, and the extent of the fibrous tissue-changes in the esophageal wall. Mortality from the endoscopic procedure is almost nil, and if gastrostomy is done early in the tightly stenosed cases, ultimate cure may be confidently expected with careful though prolonged treatment.