Dysphagia in children: causes, symptoms, diagnosis, treatment

Dysphagia (swallowing disorder) is described as a sensation of difficulty in swallowing liquid or thick food, regardless of the true causes and localization of the defect. This phenomenon is based on diseases of the cricopharyngeal muscle and proximal esophagus, caused by pathology of the skeletal muscles. Among the disorders that lead to dysphagia, the following can be distinguished:

• violation of the swallowing reflex;
• mechanical obstruction;
• impaired motor activity;
• gastroesophageal reflux.

Among the reasons for the disruption of the swallowing process, the following can be distinguished:

• neuromuscular diseases, which include congenital and acquired diseases of the central and peripheral nervous systems (vascular disorders, multiple sclerosis, Parkinson's disease, brain stem tumors, pseudobulbar palsy, peripheral neuromyopathies: myasthenia, poliomyelitis, dermatomyositis);
• mechanical obstruction due to enlargement of the thyroid gland, lymphadenopathy, oropharyngeal carcinoma, congenital defects, inflammatory diseases, hyperostosis of the cervical vertebrae;
• iatrogenic defects associated with surgical manipulations in the oropharynx, radiotherapy, damage to the cranial nerves innervating the oropharynx.

Among the main clinical symptoms of swallowing disorder, the following should be noted:

• oropharyngeal dysphagia of liquid and solid food;
• oropharyngeal dysphagia with primary impairment of the reflex mechanisms of the act of swallowing (often combined with speech impairment, paresis of the tongue and pulmonary aspiration);
• nasopharyngeal regurgitation.

Differential diagnosis should be made with achalasia of the cricopharyngeal muscle, gastroesophageal reflux and Zenker's diverticulum. Diagnostics is based on barium X-ray, video radiography, endoscopy and video endoscopic analysis, manometry.

Zenker's diverticulum.

Zenker's diverticulum is a hernia of the pharyngeal mucosa at the junction of the pharynx and esophagus. The diverticulum penetrates dorsally between the circular and oblique parts of the cricopharyngeal muscle. During the act of swallowing, food may enter the hernial sac before entering the esophagus. This causes symptoms of dysphagia and regurgitation of undigested food from Zenker's diverticulum.

The cause of Zenker's diverticulum is unclear. Most likely, an important role is played by the features of the anatomical structure. In addition, dysfunction of the upper esophageal sphincter, the upper part of the esophagus, may also play a role in the development of Zenker's diverticulum. Currently, there are two hypotheses explaining the development of Zenker's diverticulum: a violation of the clear coordination between the moment of relaxation of the upper esophageal sphincter and contractions of the pharynx; a violation of the opening of the upper esophageal sphincter associated with fibrous or degenerative changes in muscle fibers.

The clinical picture is characterized by regurgitation of undigested food, dysphagia, a feeling of fullness in the neck, especially after eating, loss of appetite, cough, suffocation attacks, and salivation. Difficulty in the passage of food in the cricopharyngeal region is noted. Disturbances are noted immediately after birth, during the first month of life, and are mainly represented by ineffective reflex relaxation and pathologically high resting pressure of the upper esophageal sphincter. Low resting pressure of the upper esophageal sphincter is characteristic of a group of neuromuscular diseases - myasthenia gravis, poliomyelitis, muscular dystrophy, accompanied by an increased risk of aspiration of the contents of the esophagus. Disturbances in the relaxation process of the upper esophageal sphincter include an increase in the time of its relaxation, inefficiency, and premature closure. Cricopharyngeal achalasia is characterized by its incomplete relaxation. Premature closure of the upper esophageal sphincter plays a significant role in the pathogenesis of Zenker's diverticulum.

Differential diagnosis is carried out with diseases that lead to disruption of the swallowing process, esophageal stricture and tumors.

Treatment includes a rational diet, pneumatic dilation and myotomy. In case of severe developmental delay, feeding through a nasogastric tube (short-term) or through a formed gastrostomy (long-term) is possible. Dilation is indicated for children with cricopharyngeal achalasia and discoordination of this zone. Cricopharyngeal myotomy in case of dysfunction of the upper esophageal sphincter should be resorted to only in extreme cases.

Functional diseases of the esophagus

The importance of functional disorders of the esophagus in pediatric gastroenterology is determined by their frequency and prevalence. They are formed during periods of the most intensive growth and functional organ maturation, when physiological processes are still unstable and easily subject to disorders, in connection with which functional disorders of the esophagus are more often observed in childhood and adolescence. Long-term functional disorders of the motor activity of the esophagus often lead to morphological changes.

Disorders of the motor activity of the esophagus are divided into primary, secondary and non-specific.

Achalasia of the cricopharyngeal muscle. Achalasia is a fairly common disorder of the upper esophageal sphincter, an integral component of which is the cricopharyngeal muscle. This condition consists of insufficiently rapid relaxation of the cricopharyngeal muscle in response to food entering the upper esophageal sphincter zone and, as a result, difficulty in the passage of food from the pharynx to the esophagus ("food gets stuck in the pharynx"). The passage of both liquid and solid food is difficult. Often, difficulties in the passage of food lead to choking, aspiration into the respiratory tract, patients become afraid to eat and quickly lose weight. The disease is often accompanied by the formation of pharyngoesophageal diverticula, which are manifested by a loud rumbling in the neck when swallowing, regurgitation.

Hypertensive esophageal dyskinesia (esophagospasm, diffuse esophageal spasm, achalasia, cardiospasm, hiatospasm). The multiplicity of names indicates the lack of consensus on the localization and nature of this form of esophageal dyskinesia. Diffuse esophageal spasm (DES) is based on a primary motor dysfunction of the lower 2/3 of the esophagus with normal functioning of the proximal section, as a result of which relaxation of the cardia is delayed after the act of swallowing. Despite sufficient study of this issue and even the creation of a biological model, to this day some clinicians equate the concepts of esophagospasm and achalasia, while others, on the contrary, divide them into such nosological forms as megaesophagus, local spasm, and diffuse spasm.

Diffuse spasm of the esophagus is a polyetiological disorder of its function. Most researchers believe that the cause of esophageal spasm is a disorder of the neurovegetative innervation of the organ due to functional disorders of the nervous system (neurosis), mental trauma, etc. A certain role is played by heredity, general hypodynamia, nutritional status, acceleration, and inflammatory lesions of the mucous membrane of the esophagus. When studying the ultrastructure of nerve fibers in diffuse spasm of the esophagus, the presence of degenerative processes in them was shown, without damage to the nerve vegetative ganglia. The main link in the pathogenesis of diffuse spasm of the esophagus is a violation, or shutdown of the sequential alternation of post-swallowing peristaltic contractions of the esophagus. They are replaced by strong spastic contractions of varying amplitude, which sometimes cover significant areas of the esophagus and gradually lead to muscle hypertrophy. These non-peristaltic contractions vary in strength and duration. Instead of relaxation, muscle contractions occur during the passage of food: they appear outside the act of swallowing and disappear with the next peristaltic wave. With diffuse esophageal spasm, epithelial hyperplasia, parakeratosis, interstitial edema, and sclerosis of the cardia develop.

Despite the name of this functional disorder - "diffuse spasm of the esophagus", according to the extent of the spasmodic area, its widespread and localized forms are distinguished. The localized form, as a rule, occurs in the middle or lower part of the esophagus. The greatest clinical significance is the spasm of the lower third of the esophagus, which can last from several minutes to several hours. The clinical picture is characterized by:

• pain in the esophagus radiating to the neck, arms, lower jaw;
• dysphagia;
• odynophagia (painful swallowing).

Children usually complain of pain behind the breastbone or epigastrium, a feeling of compression that occurs during a hasty meal. Painful sensations arise suddenly, sometimes in connection with negative emotions. A characteristic sign of dysphagia in diffuse spasm of the esophagus is the absence of preceding nausea: the child suddenly becomes restless, jumps up, makes futile attempts to swallow a piece of food stuck in the esophagus. Cases of the so-called paradoxical spasm of the esophagus may be observed. Spasm occurs when swallowing liquid food and even liquids, in particular cold water. Dysphagia may be accompanied by regurgitation. Expressed and frequent regurgitation leads to weight loss. Long-term spasm of the esophagus causes expansion of the section of the esophagus above the spasm. In such cases, regurgitation becomes rarer, but much more abundant. Regurgitation at night can lead to pulmonary aspiration. Symptoms such as shortness of breath and palpitations observed in adult patients are usually absent in children.

Differential diagnosis includes gastroesophageal reflux disease (GERD), achalasia, scleroderma, carcinoma and ischemic heart disease.

Diagnostic procedures include endoscopy, fluoroscopy, manometry.

Non-specific disorders of esophageal motility. Rare syndromes. Nutcracker esophagus (syn.: symptomatic esophageal peristalsis). In addition to the hypertensive form of esophageal dyskinesia or idiopathic diffuse esophageal spasm, which is the most nosologically defined form of functional pathology of the esophagus, there are other functional disorders of this organ. Two types of such disorders are described: the hypermotile form - hypertensive peristaltic contractions ("nutcracker esophagus") and non-specific motor disorders of the esophagus.

The etiology of "nutcracker esophagus" and non-specific motility disorders (NMD) of the esophagus is unknown. A number of authors consider it the onset of achalasia. A link with gastroesophageal reflux and stress has been proven.

Symptomatic esophageal peristalsis or "nutcracker esophagus" is the basis of a clinical syndrome that is a phenocopy of angina pain combined with dysphagia.

Esophageal motility disorder is characterized by increased peristalsis (the X-ray picture resembles a nutcracker in shape) with a significant increase in the strength and length of the peristaltic wave. The diagnosis is based on the results of a manometric study, in which the pressure during the peristaltic wave reaches 200 mm Hg with a duration of more than 7.5 seconds.

Non-specific motor disorders of the esophagus (rare syndromes)

• Mershö-Kamp syndrome is a segmental contraction of the esophagus that causes dysphagia and chest pain.
• Barszton-Teschwondorf syndrome- multiple segmental spasms of the esophagus at different levels (esophagus like a pearl necklace), accompanied by attacks of painful dysphagia, regurgitation of food and retrosternal pain.
• Code's syndrome: dysphagia, chest pain when swallowing and at rest, slight dilation of the esophagus and retention of food above the cardia, caused by increased tone of the lower esophageal sphincter (dyschalasia).
• Starom Terracolla - dysphagia, hoarseness, pain in the throat and behind the breastbone with cervical osteochondrosis. One of the variants of the syndrome "cervical migraine".
• Barre-Lieou syndrome is a severe dysphagia caused by neurovascular disorders of the cervical spine.
• Bertschi-Rochen syndrome-dysphagia in cervical spine injuries at the level of C4-Th1,
• Heberden's syndrome- chest pain and dysphagia in pathology of the cervicothoracic spine at the level of C4-T4.
• Larmitte-Monnier-Wiener syndrome - spastic pharyngeal-esophageal dysphagia with vagotonia
• Muggia syndrome - spasms of the esophagus, up to gestation, with a violation of calcium metabolism (hypocalcic dysphagia).
• Kostszmia syndrome- severe dysphagia, pain in the throat and tongue caused by malocclusion.
• Hildger's syndrome - neurovegetative disorders of swallowing and pain in the back of the head with hemodynamic disturbances in the carotid artery basin.
• Furius syndromeis a severe pain behind the sternum caused by spasm and stenosis of the cardiac part of the esophagus (cardia-cardiac syndrome).
• Tipre-Richsert syndromeis achalasia of the cardia in infants, manifested by dysphagia and regurgitation (perverted Neuhaus-Wehrenberg syndrome).

It is often simply impossible to make a clear distinction between nonspecific and primary esophageal motility disorders (achalasia, diffuse esophageal spasm, and nutcracker esophagus). Many patients with NMS with dysphagia and chest pain demonstrate various types of esophageal contractions that do not fit the criteria for primary esophageal motility disorders. They are interpreted as NMS. The table presents an attempt to present NMS as syndromes.

Unlike the group of secondary disorders of the esophageal motor function, the treatment of the above-mentioned diseases is ineffective. Most clinicians suggest using nitrates, calcium channel blockers, hydralazine, and anticholinergic drugs as initial therapy due to their relaxing effect on smooth muscles. Psychotropic drugs may be used to relieve stressful situations that aggravate and maintain motor disorders. However, a single pharmacological tactic for managing these patients has not yet been developed. If drug treatment is unsuccessful, bougienage and pneumatic dilation are used, and as a last resort, esophagomyotomy.

[ 1 ], [ 2 ], [ 3 ], [ 4 ], [ 5 ]