Akhalaziya of a sebesten
Akhalaziya of a sebesten (cardiospasm) – the neuromuscular pathology of a gullet caused by changes of an esophageal vermicular movement and tone, lack of reflex opening of a kardialny opening during the act of swallowing and which is followed by violation of hit of food masses from a gullet in a stomach. Akhalaziya of a sebesten is shown by a dysphagy, a regurgitation and pains in an epigastriya. As the leading methods of diagnostics of an akhalaziya of a sebesten serve the gullet roentgenoscopy, an ezofagoskopiya, an ezofagomanometriya. Conservative treatments of an akhalaziya of a sebesten consists in carrying out pneumocardiodilatation; surgical – in performance of a kardiomiotomiya.
Akhalaziya of a sebesten
Akhalaziya of a sebesten in medical literature is sometimes designated by terms , a cardiospasm, idiopathic expansion of a gullet. Akhalaziya of a sebesten, according to different data, makes from 3 to 20% of all diseases of a gullet in gastroenterology. Among the reasons causing violation of passability of a gullet, the cardiospasm is on the third place after cancer of a gullet and postburn cicatricial .
Pathology with an identical frequency affects women and men, develops at the age of 20-40 years more often. At a sebesten akhalaziya as a result of neuromuscular violations the vermicular movement and a tone of a gullet decreases, there is no reflex relaxation of an esophageal sphincter when swallowing that complicates evacuation of food from a gullet in a stomach.
Sebesten akhalaziya reasons
The set of etiologichesky theories of an origin of an akhalaziya of a sebesten which connect development of pathology with congenital defect of nervous textures of a gullet, secondary damage of nervous fibers at a tubercular bronkhoadenit, infectious or viral diseases is put forward; deficiency of vitamin B etc. The concept of violations of the central regulation of functions of a gullet considering a sebesten akhalaziya as a result of the psychological injuries leading to disorder of cortical neurodynamics, an innervation of a gullet, a diskoordination in work of a kardialny sphincter is distributed. However up to the end the factors promoting development of a disease remain obscure.
The leading role in pathogenesis of an akhalaziya of a sebesten is assigned to defeat of departments of the parasympathetic nervous system regulating motility of a gullet and stomach (in particular an auerbakhovsky texture). The secondary (symptomatic) akhalaziya of a sebesten can be caused by infiltration of a texture a malignant tumor (a stomach adenocarcinoma, gepatotsellyulyarny cancer, limfogranulematozy, lung cancer, etc.). In some cases the auerbakhovsky texture can be surprised at a myasthenia, a hypothyroidism, a poliomiozita, system red a wolf cub.
The actual denervation of the top departments of a GIT causes decrease in a vermicular movement and tone of a gullet, impossibility of physiological relaxation of a kardialny opening during the act of swallowing, a muscular atoniya. At such violations food comes to a stomach only thanks to mechanical disclosure of the kardialny opening occurring under the hydrostatic pressure of the liquid food masses which accumulated in a gullet. Long stagnation of a food lump leads to expansion of a gullet – to a megaezofagus.
Morphological changes in a wall of a gullet depend on duration of existence of an akhalaziya of a sebesten. In a stage of clinical manifestations narrowing of a sebesten and expansion of a gleam of a gullet, its lengthening and S-shaped deformation, a posterization of a mucous membrane and smoothing of a skladchatost of a gullet is noted. Microscopic changes at an akhalaziya of a sebesten are presented by the hypertrophy of gladkomyshechny fibers, growth in an esophageal wall of connecting fabric expressed by changes in intermuscular nervous textures.
Classification of an akhalaziya of a sebesten
Among a set of the offered options of classification of an akhalaziya of a sebesten allocation of stages of a disease is of the greatest clinical interest.
The I stage of an akhalaziya of a sebesten is characterized by an intermittiruyushchy spasm of kardialny department. Macroscopic changes (a stenosis of a sebesten and suprastenotichesky expansion of a gleam of a gullet) are not noted. At the II stage of a disease the spasm of a sebesten has stable character, insignificant expansion of a gullet is observed. At an akhalaziya of a gullet of the III stage cicatricial deformation of a muscular layer of a sebesten and sharp suprastenotichesky expansion of a gullet comes to light. The IV stage of an akhalaziya of a sebesten proceeds with sharply expressed stenosis of kardialny department and considerable dilatation of a gullet. It is characterized by the phenomena of an ezofagit with an ulceration and necroses mucous, periezofagity, a fibrous mediastinit. In foreign researches allocate a diskhalaziya as an akhalaziya prestage with the alternating disorders of function of a sebesten.
According to radiological signs allocate two types of an akhalaziya of a sebesten. The first type of pathology is characterized by moderate narrowing of a disteel piece of a gullet, a simultaneous hypertrophy and dystrophy of his circular muscles. Dilatation of a gullet is expressed moderately, the site of expansion has the cylindrical or oval forms. Akhalaziya of a sebesten of the first type occurs at 59,2% of patients.
Speak about the second type of an akhalaziya of a sebesten at considerable narrowing of the disteel site of a gullet, an atrophy of its muscular cover and partial replacement of muscle fibers with connecting fabric. Expansion of suprastenotichesky department of a gullet and its S-shaped deformation is noted expressed (to 16-18 cm).
Akhalaziya of a sebesten of the first type can progress in the second type over time. Knowledge like akhalaziya of a sebesten allows gastroenterologists to provide possible difficulties when carrying out pneumocardiodilatation.
On expressiveness of violations of functions of a gullet and a sebesten allocate stages of compensation, a decompensation and a sharp decompensation.
Sebesten akhalaziya symptoms
As clinical manifestations of an akhalaziya of a sebesten serve the dysphagy, a regurgitation and zagrudinny pains. The dysphagy is characterized by difficulty of swallowing of food. In certain cases violation of the act of swallowing develops in one stage and proceeds steadily; usually the dysphagy is preceded by flu or other viral disease, a stress. At a part of patients the dysphagy has incidental character in the beginning (for example, at hasty food), then becomes more regular, complicating passing both dense, and liquid food.
The dysphagy at an akhalaziya of a sebesten can be selective and arise at the use only of a certain type of food. Adapting to swallowing violation, patients can independently find ways of regulation of passing of food masses – to hold the breath, to swallow air, to wash down food with water etc. Sometimes at an akhalaziya of a sebesten the paradoxical dysphagy at which passing of liquid food is at a loss more than firm develops.
Regurgitation at an akhalaziya of a sebesten develops as a result of the return throwing of food masses in an oral cavity at reduction of muscles of a gullet. Expressiveness of a regurgitation can have character of small vomiting or esophageal vomiting when plentiful vomiting by "a full mouth" develops. Regurgitation can be periodic (for example, in the course of food, along with a dysphagy), to arise right after meal or 2-3 hours later after food. Less often at a sebesten akhalaziya the throwing of food can happen in a dream (a so-called, night regurgitation): at the same time food quite often gets into airways that is followed by "night cough". The small regurgitation is characteristic of the I-II stage of an akhalaziya of a sebesten, esophageal vomiting – of the III-IV stages when there is an overflow and restretching of a gullet.
Pains at an akhalaziya of a sebesten can disturb on an empty stomach or in the course of meal when swallowing. Pain is localized behind a breast, often irradiates in a jaw, a neck, between shovels. If at the I-II stage of an akhalaziya of a sebesten of pain are caused by a muscles spasm, then at the III-IV stage – developing ezofagity. Periodic pristupoobrazny pains - ezofagodinichesky crises which can develop against the background of nervousness, of physical activity, are typical for an akhalaziya of a sebesten at night and to last of several minutes till one o'clock. The painful attack sometimes passes independently after vomiting or passing of food masses to a stomach; in other cases it is stopped by means of spazmolitik.
Violation of passing of food and continuous vomiting lead to weight loss, disability, decrease in social activity. Against the background of characteristic symptomatology at patients from an akhalaziy sebesten nevrozopodobny and affective states develop. Quite often sick it is long and are unsuccessfully treated at the neurologist concerning these frustration. Meanwhile, nevrogenny violations practically always regress after treatment of an akhalaziya of a sebesten.
Diagnostics of an akhalaziya of a sebesten
Except typical complaints and data of fizikalny inspection, in diagnostics of an akhalaziya of a sebesten results of tool researches are extremely important. Inspection of the patient at suspicion on an akhalaziya of a sebesten is begun with a survey X-ray analysis of a thorax. At identification on the roentgenogram of a shadow of an expanded gullet with the level of liquid carrying out a X-ray analysis of a gullet with preliminary reception of a baric suspension is shown. The radiological picture at an akhalaziya of a sebesten is characterized by narrowing of final department of a gullet and expansion of the overlying site, a S-shaped form of body.
By means of an ezofagoskopiya the stage and type of an akhalaziya of a sebesten, existence and expressiveness of an ezofagit is specified. For an exception of cancer of gullet the endoscopic biopsy with the subsequent morphological research of a bioptat is carried out. For assessment of sokratitelny function of a gullet and a tone of a kardialny sphincter the ezofagealny manometriya registering the intra esophageal pressure and a vermicular movement is carried out. A typical manometrical sign of an akhalaziya - lack of a reflex of disclosure of a sebesten when swallowing.
As valuable diagnostic criterion of an akhalaziya of a sebesten serve results of pharmacological tests with karbakholiny or acetylcholine: at their introduction there are not propulsive chaotic reductions of muscles in chest department of a gullet and strengthening of a tone of the lower esophageal sphincter that indicates denervatsionny hypersensitivity of body.
Treatment of an akhalaziya of a sebesten
Treatment at an akhalaziya of a sebesten provides elimination of a cardiospasm and can be carried out by means of conservative or surgical methods, sometimes – medicinal therapy. A conservative method of elimination of an akhalaziya of a sebesten is pneumocardiodilatation – balloon expansion of a kardialny sphincter which is carried out step by step, cylinders of different diameter with consecutive increase in pressure. By means of cardiodilatation restretching of an esophageal sphincter and decrease in its tone is reached. Cracks and ruptures of a gullet, development a reflux-ezofagita and cicatricial a kardialny sphincter can become complications of balloon dilatation.
The resistant result of treatment of an akhalaziya of a sebesten is achieved after surgical intervention - an ezofagokardiomiotomiya – a sebesten section with the subsequent plasticity (fundoplikatsiy). Operation is shown at a sebesten akhalaziya combination to hernia of an esophageal opening of a diaphragm, gullet diverticulums, cancer of a kardialny part of a stomach, unsuccessfulness of tool dilatation of a gullet, its gaps.
If the akhalaziya of a sebesten is combined with stomach ulcer of a duodenum, the selective proximal vagotomiya is in addition shown. In the presence of heavy peptic erosive and ulcer the reflux-ezofagita and the expressed atoniya of a gullet is made a proximal resection of a stomach and an abdominal part of a gullet with imposing of an invaginatsionny ezofagogastroanastomoz and piloroplastik.
Medicinal therapy at an akhalaziya of a sebesten plays a supporting role and is directed to remission extension. Purpose of antidofaminergichesky medicines (metoklopramid), spazmolitik, small tranquilizers, antagonists of calcium, nitrates is for this purpose expedient. In recent years for treatment of an akhalaziya of a sebesten maintaining a botulotoksin is used. As important points at an akhalaziya of a sebesten serves observance of the sparing diet and diet, normalization of an emotional background, an overstrain exception.
Forecast and prevention of an akhalaziya of a sebesten
Current of an akhalaziya of a sebesten slowly progressing. Untimely treatment of pathology is fraught with bleeding, a gullet wall perforation, development of a mediastinit, the general exhaustion. Akhalaziya of a sebesten increases risk of development of cancer of gullet.
After carrying out pneumocardiodilatation the sebesten akhalaziya recurrence in 6-12 months is not excluded. The best predictive results are connected with lack of irreversible changes of motility of a gullet and early performing expeditious treatment. Dispensary observation of the gastroenterologist with implementation of necessary diagnostic procedures is shown to patients from an akhalaziy sebesten.