Achalasia of the cardia - Causes, symptoms and treatment. MF.

The cardiac section of the esophagus, or the lower esophageal sphincter, is located in the area of ​​the esophagus into the stomach and performs the function of muscle pulp that relaxes when food moves into the stomach and closes to prevent the gastric contents into the esophagus. This functioning of the cardia muscles is regulated by the autonomic nervous system, represented by nuclei in the brain, giving off "commands" and nerves that conduct signals to the esophagus wall and its sphincters.

When the vegetative regulation of the lower esophageal sphincter changes, the synchronous operation of the lower esophageal sphincter is disturbed, as a result of which food that enters the esophagus and normally irritates its walls and sphincter for opening the esophagus lasts longer than usual in the esophagus. With the long existence of such disorders, food stretches the walls of the esophagus, which leads to an increase in its lumen. The described processes are characteristic for achalasia of the cardia.

Cardiac Achalasia is a fairly common disease and occurs with equal frequency among males and females. There are several stages of the process:

- Stage 1 is characterized by the presence of a transient spasm of the lower sphincter of the esophagus, and there is no stretching of the esophageal walls,
- for the 2 stage there is a stable stretching of the walls and pronounced disturbances in food progression to the stomach,
- in 3 stages of cardiac spasm is alreadynot only functional, but also organic, since muscle fibers germinate with scar tissue and develop scar cervical stenosis,
- stage 4 is characterized by the development of complications.

A similar classification is used by physicians to determine the tactics of treatment and monitoring the patient.

Causes of the disease.

Despite the fact that intensive studies in the field of esophagus diseases have been carried out in recent years, the exact causes of achalasia of the cardia have not been identified. The following assumptions are made about the triggers, which cause disturbances in the tone of the cardia muscles. These include:

- psychoemotional stresses, leading to disruption of all internal organs, especially the gastrointestinal tract,
- congenital or acquired disorders of the autonomic nervous system,
- pathological processes inside the esophageal wall affecting the neuromuscular plexus,in particular, Auerbach's plexus, responsible for the contractile activity of the muscular wall of the esophagus. Symptoms of achalasia of cardia.

Clinical signs of the disease are composed of the following syndromes:

1. Dysphagia syndrome .By dysphagia means the violation of swallowing solid or liquid food, caused by a violation of the patency of the esophagus. Clinically manifested by the sensation of "lump" and bursting in the chest, the inability to swallow, popperhivaniem during meals. Solid food passes more easily than liquid food, since the mechanical pressure of the solid lump promotes the opening of the sphincter, and the force of the fluid pressure is not sufficient to open the muscles. It is important to know the doctor, because organic diseases of the esophagus( cancer, stenosis, adhesions) are characterized by the inability to swallow solid food, while the liquid is easily swallowed and flows through the narrowed section of the esophagus.

2. The syndrome of regurgitation of , or the reverse casting of food, eaten the day before, into the oral cavity. The patient notes periodic regurgitation immediately after a meal or at night, when he takes a horizontal position. In some cases, the volume of leaky food can reach a considerable size.

3. The painful syndrome of is caused by the dilatation of the walls of the esophagus and the pressure of the food lump on the lower esophageal sphincter, which is in a spasmodic state. It is characterized by a feeling of bursting pain in the chest, arising at the time of swallowing food or a few hours after eating. Pain can appear regardless of food intake, for example, with exercise, and last from several minutes to several hours.
Pains in the chest are often combined with nausea and vomiting eaten on the eve of food, with frequent eructations and with an unpleasant odor from the mouth.

4. Asthenic syndrome occurs due to impaired absorption of nutrients, manifested by a lack of appetite and a decrease in body weight. The emergence of such complaints is due not only to a decrease in the intake of nutrients in the body, but also to the psychoemotional component, since the patient is in a depressed state because of the discomfort that occurs when eating.
The course of the disease is characterized by periodicity with exacerbations and remissions. The first two stages of achalasia of the cardia last from several months, the last, with the formation of organic changes in the wall of the esophagus and the development of complications, can last for years.

Diagnosis of cardiac achalasia.

If such symptoms appear, the patient should consult a physician or gastroenterologist. After detailed examination and examination, the doctor will prescribe additional methods of investigation, which include:

- general blood and urine tests as routine methods of examination,
- chest X-ray survey and radiocontrast study of the esophagus with barium suspension( esophagography), which as a result of achalasiacardia, you can see the shadow of the enlarged esophagus and the narrowed section above the entrance to the stomach,

The arrow indicates the narrowing of the lower esophageal sphincter, over which the enlarged shadow is visualizedesophagus.

- endoscopic examination - esophagoscopy or PHEGS, which allows visual inspection of the esophageal mucosa, which is especially important in differential diagnosis with other diseases,
- esophagomanometry is a method that allows to measure pressure in the lumen of the esophagus and its sphincter during swallowing and at rest.

Treatment of achalasia of cardia.

Treatment of the disease includes medical therapy and surgical treatment.

In the early stages of the disease, it is preferable to perform minimally invasive procedures in combination with conservative therapy to prevent the development of complications and cicatricial degeneration of the lower esophageal sphincter. In the later stages, surgical treatment is combined with the administration of medications.

With , the following groups of drugs are prescribed for drug treatment of :

- Nitrates are analogues of nitroglycerin. Have a pronounced relaxing effect on the musculature of the lower esophageal sphincter, and in addition, promote the normalization of esophageal motility. Nitrosorbide - prolonged form of nitroglycerin is more often appointed from this group. Possible side effects, such as severe headache, dizziness and lower blood pressure.
- Calcium antagonists - verapamil and nifedipine( corinfar).Have similar effects with nitroglycerin.
- Prokinetics - motilium, ganaton, etc. Promote the normal motor skills of the esophagus and other parts of the gastrointestinal tract, ensuring the progress of the food lump in the stomach.
- Spasmolytics - drotaverin( no-spa), papaverine, platyphylline, etc. Effectively affect the smooth muscle fibers of the cardia, eliminating the spasm of the lower esophageal sphincter.
- Sedation therapy is used to normalize the emotional background of patients. They are applied as herbal( St. John's wort, sage, motherwort, valerian), and medicinal preparations.

Pneumocardiodilation refers to minimally invasive methods of treatment and consists of a course of procedures with an interval of every 4-5 days. Dilation is carried out by inserting a balloon of a certain diameter( 30 mm or more) into the lumen of the cardia under X-ray control or without it. Before the procedure, a premedication is shown - intravenous administration of solutions of atropine and diphenhydramine to reduce pain and vomiting. The essence of the method is to obtain an expansion of the cardia by stretching or tearing the muscle fibers in the constriction zone. Already after the first procedure, a significant number of patients note the elimination of unpleasant symptoms of achalasia of the cardia.

Surgical treatment of is performed in the late stages of the disease, as well as in cases where the use of cardiodilation failed. The essence of the operation consists in dissection of the muscular layer of the cardiac section with subsequent suturing in the other direction and covering the sewn part with the wall of the stomach.

Lifestyle with cardiac achalasia.

To improve the quality of life, as well as to prevent relapses, the patient should take the following steps to improve his or her lifestyle:

- development of the optimal work and rest regime,
- organization of a clear daily routine,
- sleep with a raised head, in a well-ventilated room,
- long stay in the fresh air, morning exercises, walking,
- proper nutrition -in small portions 4-5 times a day, eliminating overeating at night, excluding products that have irritating effects on the stomach( fatty, fried, spicy, salty foods and spices), thoroughly chewing food, drinking down eaten porkand a glass of warm water.

Complications.

Complications that develop during the course of the natural course of the disease without treatment include:

- scarring of the cardial department,
- inflammatory diseases of the esophagus - esophagitis,
- malignant degeneration of the esophagus mucosa,
- depletion of the body due to disruption of nutrient intake,cases - cachexia( marked exhaustion) of the patient,
- aspiration pneumonia due to ingestion of food particles in the respiratory tract and hard to treatNIJ.
The development of complications resulting from surgical treatment is extremely rare, such as:
- esophageal wall perforation and bleeding in balloon cardiodilation,
- reflux esophagitis due to gastric acid reflux into the esophagus and irritation of its walls with acidic gastric juice,
- peptic ulcersand strictures( adhesions) of the esophagus, caused by the same factors as reflux esophagitis.

Forecast.

The prognosis without treatment is unfavorable, because the course of the process is steadily progressing, resulting in disability of the patient and death due to exhaustion and dystrophy of all internal organs.

The prognosis of the disease treated is favorable, as in most cases it is possible to achieve the elimination of symptoms and prevent recurrence of the disease. With surgical correction of cardiac achalasia, the recurrence rate for 25 years after surgery is only 3%.

Doctor therapist Sazykina O.Yu.