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Cardia achalasia

Cardia achalasia (a cardiospasm, megaezofag, an idiopathic esophagectasia, etc.) — a chronic neuromuscular disease of a gullet at which passing of food masses on a gullet and from a gullet in a stomach owing to pathological changes of an esophageal vermicular movement and lack of reflex disclosure of the cardia is broken during swallowing.

Epidemiology
The disease rather rare (according to different data, makes up to 3% of diseases of a gullet), affects equally both men, and women, arises aged from 20 till 40 flyings more often.

Etiology and pathogeny
There were theories of inborn defect of neuroplexes of a gullet, however at children the disease is observed very seldom. Also secondary damage of neuroplexes of a gullet and nearby nerves at a tubercular bronchadenitis was supposed; however in the last decades the frequency of a tubercular bronchadenitis considerably decreased, the frequency of incidence of an achalasia of the cardia did not change. The great value was allocated for the central disturbances of regulation of functions of a gullet as at some patients this disease develops as if directly after stressful situations; however the examination conducted soon after emergence of nervous symptoms of an illness is frequent, demonstrates the old, far come organic process in a gullet: at this moment already considerable expansion and its S-shaped curvature is defined.

More possibly infectious and toxic (perhaps, virus) defeat of neuroplexes of a gullet.

Classification
Distinguish the I type of an achalasia of the cardia (with a moderate esophagectasia) and II, characterized by considerable lengthening of a gullet, it is frequent with its S-shaped curvature. On extent of dysfunction of the cardia and a gullet allocate 3 stages: compensations, a decompensation and sharply expressed decompensation.

Approximate formulation of the diagnosis: 1. Cardia achalasia, II type, decompensation stage.

Clinical picture, preliminary diagnosis
The anamnesis is essential. Main symptoms: disturbance of a proglatyvaniye (dysphagy), esophageal vomiting (regurgitation) and retrosternal pain. The dysphagy in one cases arises at once and keeps steadily — often after nervous stresses" sometimes — after any grippopodobny disease. In other cases the dysphagy arises incidentally, generally at hasty food in the beginning, then appears in increasing frequency, passability on a gullet not only dense food, but liquid is broken (broth, fruit juice and even water).

Parallel to increase of a dysphagy because of accumulation of food in a gullet esophageal vomiting (the return receipt of contents of a gullet in a throat and a mouth after food arises and amplifies, at an inclination of a trunk and in a prone position, especially at night during a dream). Gullet contents at the same time can get into airways, causing a strong fit of coughing, asthma, aspiration pneumonia. Certain patients at gradual development of symptoms of an illness develop the special receptions facilitating passing of food to a stomach (curve a trunk back at emergence of a dysphagy, drink off a glass of warm water, etc.) that allows them to support the food at rather satisfactory level; these patients often long do not see a doctor. Pain behind a breast arises at overflow of a gullet or is spontaneous.

The diagnosis is confirmed by X-ray inspection: disturbance of passing of a baric contrast suspension from a gullet in a stomach, existence on an empty stomach in a gullet of a large number of contents (the food eaten the day before, the drunk liquid, the swallowed saliva) is noted, a moderate or considerable esophagectasia, in the latter case a gullet it is also extended and quite often S-shapedly bent. The gas bubble of a stomach does not come to light. Pharmacological test with nitroglycerine (1 — 2 tablets under language) is usually positive: the contrast suspension passes at once, as if "fails" in a stomach. By means of an ezofagoskopiya reveal an esophagectasia, signs of a congestive esophagitis (owing to long stagnation in a gullet of food and favorable conditions for reproduction of microorganisms); it is characteristic that the esophagoscope rather easily passes through the cardia in a stomach.

Differential diagnosis, verification of the diagnosis
At an early stage differentiation is carried out with an esophagism (major importance has X-ray inspection), cardioesophageal cancer. In the latter case at X-ray inspection some roughness of a contour of a distal piece of a gullet, negative pharmacological test with nitroglycerine (there is no disclosure of the cardia at nitroglycerine reception) is noted, the gas bubble of a stomach is almost always visible. The diagnosis of cancer is confirmed by an ezofagoskopiya with an aim biopsy. The cicatricial stricture of a distal piece of a gullet is also shown by a dysphagy, however the incompetence of cardia leading to emergence a reflux esophagitis and a round ulcer of a gullet therefore development of a dysphagy in these cases is usually preceded by the long period of persistent complaints to heartburn is the most frequent reason of a cicatricial stricture of a gullet. The diagnosis is established on the basis of X-ray and esophagoscopic inspection.

Treatment
Usually treatment consists in cardia stretching by means of a pneumocardiodilator, only in the started cases it is necessary to resort to surgical treatment. Treatment eliminates a dysphagy and other symptoms of a disease; the effect remains for 8 — 12 and more, when resuming a dysphagy carry out a repeated course of treatment by pneumocardiodilatation. After treatment of patients it is recommended frequent (4 — 5 times a day) fractional food, a moderate sparing diet (to avoid fried, acute, and also very hot food, cold drinks, alcohol is excluded), during food it is not necessary to distract, it is necessary to chew food especially carefully. Patients with an achalasia of the cardia have to consist on dispensary accounting at the gastroenterologist, X-ray inspection at least 1 time in a year is shown.

 
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