Achalasia cardia

Akhalasia of cardia as a disease was well characterized almost 130 years ago by the famous Russian therapist and researcher S. P. Botkin - "spasmodic or paralytic constriction" of the esophagus. The modern view relates the disease to the violation of the neuromuscular regulation of the contractions of the lower part of the esophagus (cardia).

Changes are reflected primarily in the process of passage of food into the stomach. The disease occurs at any age, including in children. Women often suffer from 20 to 40 years.

Among all the pathology of the esophagus, achalasia accounts for, according to various data, from 3 to 20%.

How does the name of the disease reflect its essence?

In medical terminology to date, there is no unity among doctors from different countries on the name of pathology, so there is confusion. This is due to the description of the disease from different angles and the emphasis of individual preemptive disorders.

So, in 1882 the term "cardiopathism of the esophagus" was introduced. German doctors insisted on the cessation of the action of the vagus nerves. Therefore this name is still used in German and Russian literature. In France, they are more accustomed to "mega-esophagus," "atony of the esophagus," and "cardiotonic enlargement."

The term "achalasia" was introduced in 1914 by Perry. He had to reconcile both sides, since in Greek means "non-relaxation". Nevertheless, everyone still has his opinion. In the International Classification of Diseases, "ahalasia" and "cardiospasm" under code K 22.0 are left on an equal footing. Congenital cardiac spasm is referred to the class of developmental anomalies (Q39.5).

The mechanism of development

Symptoms of the disease are caused by insufficient relaxation of the cardia during swallowing. The following violations are possible:

• incomplete opening;
• partial opening + spasm;
• complete achalasia;
• achalasia + spasm;
• hypertension state.

Each mechanism can not be considered separately as a cardiospasm. Usually there is a mixed nature of disturbance of innervation. As a result, the tone decreases simultaneously and the peristalsis of the esophagus increases, but it does not form the waves necessary for strength, but is represented by separate small contractions of the muscle beams in different parts of the esophageal wall in the thoracic and cervical divisions.

The food lump is longer in the esophagus. It passes into the stomach only under the influence of mechanical pressure. In the cardiac department, not only food accumulates, but also mucus, saliva, bacteria. Stagnation causes inflammation of the wall and parietal tissues (esophagitis, pereezophagitis).

The swelling following the inflammation narrows the internal opening and further worsens the permeability of the food

Pathological changes

Erroneous are those who believe that the achalasia of the cardia of the esophagus is only a functional violation. The disease has its own characteristic histological changes. The site of narrowing is located 2-5 cm above the stomach, and then there is an expansion zone up to the level of the cricoid cartilage.

The study of tissues shows the dystrophy of nerve cells of ganglia, fibers and plexuses located in the muscular layer of the cardial department. Some fibers die with muscle cells. In their place, connective tissue proliferates. The process is accompanied by massive inflammation.

In severe cases, inflammation joins:

• surrounding cellulose;
• pleura;
• mediastinum;
• aperture.

What is known about the causes?

The final clarity in identifying the cause of pathology is not yet available. Theories of the development of achalasia are proposed taking into account the pathogenesis of the disease. Each is confirmed by data from statistical studies, histological examination. The main provisions concern:

• congenital malformations with the defeat of the neural intermuscular plexus;
• manifestations of neurasthenia with impaired activity of the central parts of the brain and loss of coordination of esophageal motility;
• reflex disorders - approximately 17% of patients with different diseases develop symptomatic achalasia with reflexive opening of the cardia, these include: tumors of the upper part of the stomach, a state after a gastrectomy surgery with high vagotomy (transection of the branch of the vagus nerve), an ulcer and swelling of the abdominal esophagus, diverticula;
• infectious (mainly viral) and toxic nature of the damage to the nerve plexus and the regulation of esophagus (example, Chagas disease in countries of South America, associated with infection with Trypanosome Krusa).

Emotional overstrain, stress - refers to the triggering mechanism of the disease

In the absence of communication with any cause, they speak of an idiopathic version of achalasia of the esophagus.

Classification by types and stages

The changes accompanying the disease are divided into 2 types:

• First- observed in 30% of patients, the esophagus looks like a cylindrical body or has a spindle-shaped extension. In the narrowed part, the pronounced hypertrophy of the wall is determined, the adjacent zones are moderately compacted. The shape and walls of the organ are preserved.
• Second- is distributed in 70% of cases, the form of esophagus expansion is similar to the bag, reaches 15-18 cm in diameter, can contain up to 3 liters of food, there is lengthening and irregularity of form, muscular layer atrophy, this type was called by the French "mega-esophage".

Other suggestions are:

• type I - a disease with significant enlargement;
• type II - without a pronounced increase in the volume of the cardia.

At the same time, some researchers insist that each type is an independent disease and never goes from one form to another.

Most scientists are convinced that types represent stages of the pathological process from initial to progressive

According to the classification of B. AT. Petrovsky, the disease has 4 degrees of development:

• I - cardiospasm has a non-permanent character, is defined as functional, there is no expansion of the esophagus during examination.
• II - the spasm becomes stable, in the field of cardia there appears an unsharpening expansion.
• III - scars are found in the muscular layer, the enlargement is considerable, the form is broken;
• IV - sharp narrowing of the cardia with the expansion of the remaining part of the esophagus, accompanied by esophagitis and changes in shape to S-shaped.

Division into forms:

• hypermotile - corresponds to the first stage (degree);
• hypomotile - II stage;
• amotyl - characterizes the III-IV stage.

Symptoms and clinical course

Most often, even with acute onset of the disease due to a sudden difficulty in swallowing, when the patient is carefully questioned, it is possible to identify previous problems of discomfort and the initial symptoms of esophageal cardiopathy. Just until a certain point they were less pronounced and tolerant.

Clinicians express the opinion that the latent period of the disease is provided by a complex mechanism of compensation for violations. A worsening of symptoms contributes to nervous breakdown, stress, hasty food. They rip off compensation.

For the manifestation of cardiac achalasia, the classic triad of symptoms is typical:

• impaired swallowing (dysphagia);
• pain;
• regurgitation (backward movement to the oral cavity).

Let's consider each feature separately.

Dysphagia

The difficulty of moving food through the esophagus into the stomach is associated with impaired motor function of the muscular layer of the esophagus and regulation of the opening of the cardia.

Often patients associate the appearance of difficulty swallowing with a nervous shock, the symptom itself disappears, but then repeats itself

The disease begins with a slight difficulty in swallowing dry food with hasty food, limiting the supply of time. But it repeats itself more often, already under normal conditions. Paradoxical dysphagia is called a symptom of Liechtenstein: it's not dry food that causes difficulty, it's semi-liquid and liquid. Some patients note a temperature dependence of food: cold food does not pass or, conversely, hot food.

Pain syndrome

Pain during swallowing is located behind the breastbone, can be preserved outside eating. Usually by nature they represent:

• burning - occur on an empty stomach, after vomiting, more often associated with inflammation (esophagitis), eating improves the patient's condition;
• pressing - formed when stretching the walls of the esophagus, the accumulation of food masses in it, differ in intensity, do not disappear until the time of evacuation of the esophagus;
• spastic - are caused by spastic reduction of muscle sites, disturb at night, seizures are similar to angina, so doctors are advised to take Nitroglycerin, call an ambulance. Treatment for cardiopathy of the esophagus is always carried out under ECG monitoring.

At the beginning of the disease, pain can manifest as crises during excitement, physical exertion, at night. They are not associated with swallowing movements. Sometimes the patient has no signs of dysphagia and regurgitation at all. It is suggested that their appearance is associated with progressive dystrophic changes in the nerve plexuses of the esophagus. They differ in pronounced intensity, irradiation into the back, neck, and lower jaw.

Rarely in patients with food, symptoms of compression of the mediastinum appear. In addition to bursting and heaviness behind the sternum, shortness of breath arises before the attack of suffocation, the face and lips turn blue.

The condition improves after regurgitation or artificial vomiting

Regurgitation

An eructation or a reverse food intake with a small expansion of the esophagus is possible immediately after several sips, and against a background of a significant increase in the volume of cardia is rare, although more abundant.

It is caused by spastic contraction of the muscles of the esophagus in response to overflow. In the prone position and the torso of the trunk, the pressure of the accumulated food on the pharyngeal esophageal sphincter takes part in the regurgitation mechanism.

At night, regurgitation occurs due to a decreased tone of the upper esophageal sphincter. The danger consists in the possibility of ingestion of food residues in a dream in the respiratory tract. This can cause aspiration pneumonia.

Additional non-permanent manifestations of esophagus ahalasia include:

• aerophagia - belching with air, ingestion of air with empty swallowing movements in the initial period of the disease helps to increase the pressure in the esophagus and push the food lump;
• hydrophagy - the need to constantly drink food with water;
• characteristic behavior at the table - patients adapt to the pushing of food (walk, bounce, squeeze the neck);
• increased salivation;
• nausea;
• smell from the mouth.

Diagnostics

Laboratory methods for this disease do not play a significant role. The main method of visual inspection of the esophagus is esophagoscopy. The picture reveals a different degree of expansion, signs of inflammation, erosion, ulcers, leukoplakia. An important distinctive feature of organic lesions of the cardia is the ability to conduct an endoscopic probe through the cardiac section of the esophagus.

In a healthy person, immediately after swallowing, the wave travels along the esophagus and towards the ventral part, the entrance to the cardia opens and the internal pressure decreases. Then the lower input closes. In the case of achalasia, the cardiac sphincter does not relax when swallowed, the internal pressure increases. Various muscular contractions of the esophagus are recorded both in connection with swallowing and without it.

X-ray examination of the esophagus should be performed with contrasting

Without the use of a barium suspension for the deviation of the esophagus, it is possible to radiolandically indirectly judge by swelling of the right mediastinal contour, absent the gas bubble in the stomach. Filling of the esophagus by contrast allows to reveal:

• delay of contrast mass in the lower parts;
• narrowing of the end part of the esophagus with distinct contours;
• preservation of folds of the mucosa;
• layer of liquid and food above the barium suspension;
• different degrees of esophagus expansion over the bottleneck;
• sharp violation of peristalsis, spastic character of contractions with insufficiently full amplitude;
• with the available esophagitis, the radiologist describes the altered relief of the mucous membrane, thickening, granularity, sinuosity of the folds.

Differential diagnosis is carried out:

• with malignant neoplasm in the esophagus, cardia;
• benign tumors;
• peptic ulcers, esophagitis, stenosis;
• cicatricial changes in the esophagus after a burn;
• diffuse esophagospasm.

Sometimes it becomes necessary to diagnose pharmacological tests with Nitroglycerin, Amyl nitrite, Atropine. Against the background of the introduction of drugs, the passage of contrast medium is improved. With cancer and other stenoses this does not happen.

Treatment

Treatment of achalasia of cardia is aimed at restoring the patency of the cardial section of the esophagus.

Conservative ways

In the initial stage of the disease, it is possible to improve the condition with conservative treatment, in the future it is used to prepare the patient for surgical intervention.

Wiping food with water, a person creates an increased pressure to push it into the stomach

The food should be served in small portions 6-8 times a day. sufficient calorie content is needed, but exclusion of all irritating factors: sharply hot or cold food, fried and sharp meat, smoked products, sour fruits and berries, alcohol. All dishes should be well-cooked, sufficiently crushed. You should finish the meal 3-4 hours before bedtime.

In stages I and II, antispasmodics are shown:

• Atropine,
• Platyphylline,
• Papaverine,
• Nitroglycerine.

Help calming agents: Valerian, Bromides, Seduxen. B vitamins are shown. For patients, the shape of the drug is important: given the poor response to swallowing tablets, injections, rectal suppositories, soluble drugs are prescribed. Stagnant phenomena are removed by washing the esophagus with a weak solution of furacilin, manganese.

The method of cardiodilation (non-surgical stretching of the cardia) involves the use of a special instrument (cardi-dilator). It can be carried out at any stage.

Contraindicated in diseases with increased bleeding, portal hypertension with dilated esophagus veins, marked local inflammation (esophagitis). Use a pneumatic dilator, consisting of a rubber tube with a can on the end. The tube is injected into the esophagus and under the control of the X-ray, it reaches the cardia.

The inflation is carried out according to the scheme, the pressure is controlled by a manometer

Operative treatment

Surgical treatment is used for an unsuccessful conservative approach and cardiodilation. Usually it needs up to 20% of patients. In addition, the indications may be:

• the revealed esophageal ruptures accompanying the expansion of the cardia;
• presence of ulcers, erosions on the background of overgrowing of the cardia, which can not be conservatively treated;
• significant expansion, distortion of the esophagus, especially in combination with cardiac scars.

The operations are called "esophagocardiomyotomy". Different surgical approaches differ in the ways of access, choice of cardioplasty. But the essence of the intervention is one - the dissection of the muscles of the final section of the esophagus along the front and back walls.

In the fourth stage of achalasia it is not enough to restore the patency of the cardia. Straightening of the deformation is necessary. For this, a kind of plastic is performed: through the diaphragm, bend the esophagus into the abdominal cavity and fix it to the circular ligament of the liver. With mega-esophageal part of the esophagus is removed.

Treatment with folk remedies

Among the popular recommendations, the most appropriate means should be chosen according to the etiological principle.

• Tincture of ginseng root - is sold in a pharmacy, is shown to people with weakened immunity, frequent infectious diseases, losing weight. Take it with drops.
• Less powerful immunomodulators are tinctures of magnolia vine and aralia, aloe juice.
• A decoction of chamomile, calendula is a good mild anti-inflammatory drug.

The disease of achalasia of cardia is well treated. Therefore, when there is a symptomatology should not be tolerated for a long time. Addressing the doctor helps to find out the reason and choose the best treatment.