Cardia relaxation

Introduction The stagnation of the cardia is seen in the achalasia. Esophageal achalasia (also known as esophageal achalasia) is a esophageal functional disorder caused by neuromuscular dysfunction in the esophageal and cardiac tract. Its main features are the lack of peristalsis of the esophagus, the lower esophageal sphincter (LES) high pressure and the relaxation response to swallowing action. Clinical manifestations include dysphagia, post-sternal pain, food reflux, and cough and lung infections caused by food reflux due to inhalation of the trachea.

Cause

The cause of achalasia has not been known so far. It is generally thought to be caused by neuromuscular dysfunction. Its pathogenesis is associated with degeneration, reduction or deficiency of Auerbach ganglion cells and defects in parasympathetic distribution in the esophageal muscle layer. At the same time of ganglion cell degeneration, it is often accompanied by inflammation of lymphocyte infiltration, and the cause may be related to infection and immune factors.

Degeneration of plexus ganglion cells leads to primary achalasia. The peristalsis and tension of the esophageal wall are weakened, the end of the esophageal sphincter can not relax, and the food stays in the esophageal lumen, gradually leading to dilatation, elongation and flexion of the esophagus. Food retention can be secondary to esophagitis and ulcers, on the basis of which cancer can occur, the cancer rate is 2% to 7%.

an examination

Related inspection

Chest flat

X-ray angiography of esophagus

Swallowing examination showed esophageal dilatation, esophageal peristalsis weakened, end of esophageal stenosis was a bird's beak, and the stenosis of the mucosa was smooth, which is a typical manifestation of patients with achalasia. Henderson et al. divided the esophageal dilation into three levels: grade I (mild), esophageal diameter less than 4 cm, grade II (moderate), diameter 4-6 cm; grade III (severe), diameter greater than 6 cm, and even curved S-shaped.

2. Esophageal kinetics testing

The pressure in the lower sphincter region of the esophagus is often more than twice that of normal people, and the lower esophageal and sphincter pressures do not decrease during swallowing. The upper and middle esophageal pressures were also higher than normal. The esophageal peristaltic wave is irregular, the amplitude is small, subcutaneous injection of acetylcholine chloride 5 ~ 10mg, in some cases, the esophageal contraction is enhanced, the upper and middle esophageal pressure is significantly increased, and can cause severe pain after the sternum.

3. Gastroscopy

Gastroscopy can rule out organic stenosis or tumors. The characteristics of endoscopic achalasia are: (1) Most patients have a large amount of accumulated food in the esophagus, mostly in a semi-fluid state covering the wall, and the mucosal edema is thickened, resulting in loss of normal esophageal mucosa color; (2) The esophageal body sees dilatation and has different degrees of distortion; (3) the wall of the esophagus may have a segmental contraction ring, which may resemble a diverticulum; (4) the degree of stenosis of the cardia varies, until the complete atresia cannot pass. It should be noted that sometimes it is easy to ignore the disease when the mirror body is not clearly perceived by the cardia.

Differential diagnosis

Diagnosis of achalasia:

Clinical manifestations:

Dysphagia

Painless dysphagia is the most common symptom of the disease, accounting for 80%~95%. Symptoms of onset are more slow, but they can be more urgent. They can be mild at first, and only have a feeling of fullness after a meal. Dysphagia is often intermittent, often induced by mood swings, anger, anxiety, convulsions, or eating irritating foods such as cold and spicy. Sometimes it is difficult to swallow when the disease is early, when it is light and heavy, and later it is continuous. A small number of patients have difficulty in ingesting fluids compared to solid foods, and this sign distinguishes them from dysphagia caused by other esophageal strictures. But most patients swallow solids more difficult than liquids, or it is equally difficult to swallow solid and liquid foods.

2. Food reflux and vomiting

The incidence of food reflux and vomiting in patients with achalasia can reach 90%. As the difficulty of swallowing worsens, the esophagus expands further, and a considerable amount of the contents can remain in the esophagus for hours or days, and will flow back when the body position changes. Vomiting occurs more than 20 to 30 minutes after eating, and can vomit from the previous meal or overnight food. The contents from the esophagus are not in the stomach cavity, so there is no characteristic of vomit in the stomach, but a large amount of mucus and saliva can be mixed. In the case of concurrent esophagitis and esophageal ulcer, the reflux may contain blood.

Patients may have recurrent pneumonia, bronchitis, and even bronchiectasis or lung abscess due to food reflux and aspiration.

3. Pain

About 40% to 90% of patients with achalasia have symptoms of pain, varying in nature, and can be stuffy, burning, acupuncture, cut pain or cone pain. Most of the pain is in the back of the sternum and the upper abdomen; it can also be in the chest and back, right chest, right sternal border and left rib. Pain attacks sometimes resemble angina and can be relieved even after sublingual nitroglycerin tablets. The mechanism of pain may be due to strong contraction of the esophageal smooth muscle or food retention esophagitis. As the difficulty of swallowing gradually increases, the further expansion of the esophagus above the obstruction can gradually reduce the pain.

4. Weight loss

Weight loss is associated with difficulty in swallowing affecting food intake. For dysphagia, patients often take food, slow food, eat food or eat enough soup to wash the food, or stretch the chest and back after eating, deep breathing or suffocating to help swallow movement, make food Enter the stomach to ensure nutrient intake. However, those who have a long course of disease can still have weight loss, malnutrition and vitamin deficiency, while those with cachexia are rare.

5. Other

Patients with achalasia can often have anemia, occasionally bleeding caused by esophagitis. In later cases, the extremely dilated esophagus can compress the internal organs of the chest and produce dry cough, shortness of breath, cyanosis and hoarseness.

The disease can be diagnosed based on medical history, clinical manifestations, and laboratory tests.

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