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Achalasia cardia
Last reviewed: 22.11.2021
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Akhalasia cardia (cardiospasm, aperistaltic esophagus, megas- esophagus ) is a disease of the esophagus, characterized by the absence of a reflex opening of the cardia during swallowing and accompanied by a violation of peristalsis and a decrease in the tone of the thoracic esophagus (AL Grebenev, VM Nechaev, 1995) evacuation of food in the stomach.
Achalasia is a neurogenic disease, which is based on a violation of esophageal motility, characterized by a violation of its peristalsis and insufficient relaxation of the lower esophageal sphincter during swallowing. Symptoms of achalasia are characterized by slowly progressing dysphagia, usually with the intake of liquid and solid foods, and regurgitation of undigested food. The evaluation usually includes an X-ray study with a sip of barium, endoscopy and sometimes manometry. Treatment of achalasia consists in dilatation of the esophagus, drug denervation and surgical myotomy.
The most common disease of achalasia of cardia occurs between the ages of 25 and 50, with women more likely than men. The prevalence of cardiac achalasia is 0.5-0.8 per 100 000 population (Mayberry, 1985).
ICD-10 code
K22.0 Achalasia of the cardial part.
What causes achalasia of the cardia?
It is suggested that achalasia of cardia is associated with a decrease in the number of ganglion cells in the intermuscular neural plexus of the esophagus, leading to denervation of the esophageal musculature. The etiology of denervation is unknown, although there is a suspicion of a viral etiology of the disease; some tumors can cause achalasia with direct obstruction of the esophagus or paraneoplastic process. Achalasia can lead to Chagas disease, in which the destruction of autonomous ganglia occurs.
Increased pressure in the lower esophageal sphincter (NPC) causes its obstruction with secondary dilatation of the esophagus. Typical delay in the esophagus of undeveloped food with the development of chronic congestive esophagitis.
Symptoms of achalasia of the cardia
Achalasia of cardia can develop at any age, but usually begins at the age of 20-40 years. The onset of the disease is sudden with gradual progression for several months or years. The main sign is dysphagia when taking solid and liquid food. Night regurgitation of undigested food is observed in approximately 33% of patients and can cause cough and lead to pulmonary aspiration. Chest pain is less common, but can occur when swallowing or occur spontaneously. There is a slight weight loss in patients; if weight loss is observed, especially in elderly patients with rapid development of dysphagia symptoms, secondary aahalasia due to a tumor of the esophageal-gastric transition should be assumed.
What's bothering you?
Diagnosis of cardiac achalasia
The main research is fluoroscopy with a sip of barium, which allows to identify the lack of progressive peristaltic cuts of the esophagus during swallowing. The esophagus is often greatly dilated, but in the NPS region it is narrowed like a bird's beak. When esophagoscopy is performed, dilatation of the esophagus is revealed without any pathological formations, but the endoscope easily passes into the stomach; the difficult movement of the apparatus causes suspicion of an asymptomatic course of the tumor or stricture. To exclude malignancy, examination of the curved posterior cardiac section of the jug, biopsy and samples of mucosal scraping for cytological examination is necessary. The esophagus manometry is usually not performed, but it demonstrates the absence of peristalsis, increased pressure of the NPC and incomplete relaxation of the sphincter during swallowing.
Achalasia of cardia differentiates from carcinoma, stenosing the distal esophagus, and peptic stricture, especially in patients with scleroderma, in which manometry can also reveal the esophagus's aperostatics. Systemic sclerosis is usually accompanied by the phenomenon of Raynaud in history and signs of gastroesophageal reflux disease (GERD).
Achalasia of cardia as a result of cancer of the esophageal-gastric junction can be diagnosed with CT of the thoracic cavity and CT of the abdominal cavity or endoscopic ultrasonography.
Diagnosis of cardiac achalasia
[What do need to examine?
Treatment of achalasia of cardia
There is no any therapy that restores peristalsis; treatment is aimed at reducing the pressure (and thus the obstruction) of the NPS. As a rule, pneumatic balloon dilatation of NPS is shown. Satisfactory results are observed in approximately 85% of patients, but often repeated dilatations are required. Esophageal rupture and secondary mediastinitis requiring surgical treatment are observed in less than 2% of patients. Nitrates (eg isosorbide dinitrate 5-10 mg sublingually before meals) or Ca blockers, channels (eg nifedipine 10 mg orally 3 times a day) have limited effectiveness, but can sufficiently reduce the pressure of the NPS, prolonging the period of convalescence between dilations.
In the treatment of cardiac achalasia, chemical denervation of the cholinergic nerves of the distal esophagus can be used by direct injections of botulinum toxin into the NPS. Clinical improvement occurs in 70-80% of patients, but the results can last from 6 months to a year.
Heller's myotomy, in which the muscle fibers of the NPS are dissected, is usually used in patients whose dilation is ineffective; the efficiency of the method is approximately 85%. The operation can be performed laparoscopically or thoracoscopically and can be a definite alternative to dilation in primary therapy. Symptomatic GERD after surgical treatment develops in approximately 15% of patients.
What prognosis does cardiac achalasia have?
With timely treatment, cardiac achalasia has a life-favorable prognosis, despite the fact that the disease is fundamentally incurable. With the help of medical measures usually achieve symptomatic improvement, but lifelong observation in a specialized hospital is necessary. With pneumocarditisation or cardiomyotomy, remission lasts longer than with botulinum toxin.
Pulmonary aspiration and the presence of cancer are the determining prognostic factors. Night regurgitation and cough suggest aspiration. Secondary pulmonary complications due to aspiration are difficult to treat. The number of patients with esophageal cancer and achalasia may increase; but this point of view is controversial.