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Heartburn. Causes, diagnosis and treatment

I. Disorders of peristalsis of the thoracic esophagus

1. Hypermotor

Diffuse esophagospasm
Nonspecific movement disorders

2. Hypomotor

II. Sphincter disorders

1. Lower esophageal sphincter

Cardia failure:

Gastroesophageal reflux disease
Achalasia cardia
Cardiospasm

2. Upper esophageal sphincter

Hypermotor disturbances of peristalsis of the thoracic esophagus

Hypermotor dyskinesia of the thoracic esophagus is characterized by an increase in its tone and motility, and this can be observed not only during swallowing food, but also outside the act of swallowing. Approximately 10% of patients may not have symptoms of the disease (latent course). In this case, hypermotor dyskinesia of the esophagus can be diagnosed based on fluoroscopy of the esophagus, as well as by esophageal manometry .

The main symptoms of hypermotor dyskinesia of the thoracic esophagus are:

dysphagia - difficulty swallowing. It is characteristic that dysphagia is not constant; during the day it can appear and disappear again, it can be absent for several days, weeks, months and appear again. Dysphagia can be provoked by smoking, too hot or too cold food, hot spices and sauces, alcohol, psycho-emotional stressful situations;
chest pain - occurs suddenly, can be quite intense, can radiate to the left arm, scapula, half of the chest and, naturally, requires differential diagnosis with ischemic heart disease. Unlike ischemic heart disease, there is no connection with physical activity and there are no ischemic ECG changes;
sensation of a “lump in the throat” - occurs when the initial parts of the esophagus spasm and is observed more often with neuroses and hysteria;
jaggedness of the contours of the esophagus, local deformation and delay of the contrast mass in any part of the esophagus for more than 5 s (with fluoroscopy of the esophagus).

Segmental esophagospasm (“nutcracker esophagus”)

With this variant of esophageal dyskinesia, spasm of limited areas of the esophagus is observed. The main symptoms are:

dysphagia - characterized primarily by difficulty passing semi-liquid foods (sour cream, grated cottage cheese) and rich in fiber (fresh bread, fruits, vegetables); dysphagia is possible when consuming juices;
pain of moderate intensity in the middle and lower third of the sternum without irradiation begins and stops gradually;
spasm of limited areas of the esophagus;
spastic contractions of limited areas of the walls of the esophagus lasting more than 15 s with an amplitude of 16-18 mm Hg. (according to esophagotonocymography data)

Diffuse esophagospasm

Characteristic manifestations of diffuse esophagospasm are:

extremely pronounced pain in the sternum or epigastrium, quickly spreading upward, and also radiating along the front surface of the chest, into the lower jaw, and shoulders. The pain occurs suddenly, is often associated with swallowing, lasts a long time (from half an hour to several hours), and in some patients may disappear after a sip of water. The pain is caused by prolonged non-peristaltic contractions of the thoracic esophagus;
Paradoxical dysphagia - difficulty swallowing is more pronounced when swallowing liquid food and less when swallowing solid food. Dysphagia may become daily or appear 1-2 times a week, sometimes 1-2 times a month;
regurgitation at the end of an attack of pain;
extended and prolonged (more than 15 s) spasm of the esophageal wall (with fluoroscopy of the esophagus);
spontaneous (not associated with swallowing) contractions of the esophageal wall of high amplitude (more than 40-80 mmHg) at a distance of more than 3 cm from each other (according to esophagotonokymography).

Nonspecific motor disorders of the esophagus

Nonspecific disorders of the motor function of the esophagus occur against the background of its preserved peristalsis.

The main symptoms are as follows:

periodic appearance of pain in the upper middle third of the sternum of varying intensity, usually during eating, swallowing, and not spontaneously. As a rule, the pain is not long-lasting and can go away on its own or after taking antacids or a sip of water;
Dysphagia is rare.

With fluoroscopy, non-propulsive, non-peristaltic contractions of the esophageal wall that occur during swallowing can be observed.

Hypermotor dyskinesia of the esophagus must be differentiated primarily from esophageal cancer, achalasia cardia, gastroesophageal reflux disease and ischemic heart disease. To establish an accurate diagnosis, fluoroscopy of the esophagus, esophagoscopy, pH-metry and manometry of the esophagus, a test with the introduction of hydrochloric acid into the esophagus are used. , subsidy test with inflation of a rubber balloon in the esophagus under esophago-tono-kymographic, radiological, electrocardiographic control (the test provokes the appearance of hypermotor dyskinesia of the esophagus).

Hypomotor disturbances of peristalsis of the thoracic esophagus

Primary hypomotor disorders of esophageal peristalsis are observed rarely, mainly in elderly and senile people and chronic alcoholics. They may be accompanied by cardia failure and play a role in the development of reflux esophagitis.

About 20% of patients with hypomotor dyskinesia of the esophagus have no complaints. Other patients may have the following manifestations of the disease:

dysphagia;
regurgitation;
feeling of heaviness in the epigastrium after eating;
aspiration of the contents of the esophagus (stomach) into the respiratory tract and subsequent development of chronic bronchitis and pneumonia;
esophagitis ;
decreased pressure in the esophagus, in the area of the lower esophageal sphincter (with esophagotonocymography study).

Cardiospasm

Cardiospasm is a spastic contraction of the lower esophageal sphincter. There is still no consensus in the literature regarding the terminology of this disease. Many people identify it with achalasia cardia. Well-known specialists in the field of gastroenterology A.L. Grebenev and V.M. Nechaev (1995) consider cardiospasm as a rather rare type of esophagospasm and do not equate cardiospasm with achalasia of the cardia.

In the initial stages of the disease, the clinical picture clearly shows psychosomatic manifestations in the form of irritability, emotional lability, tearfulness, memory loss, and palpitations. Along with this, patients complain of a feeling of a “lump” in the throat, difficulty in passing food through the esophagus (“food gets stuck in the throat”). In the future, the sensation of a foreign body in the esophagus bothers patients not only during meals, but also outside meals, especially with anxiety. Very often, patients refuse to eat due to fear of intensifying these sensations. Dysphagia is often accompanied by increased breathing and complaints of lack of air. With a significant increase in breathing, it is possible to swallow food.

As a rule, along with dysphagia, patients are bothered by a burning sensation and pain behind the sternum in the middle and lower third, interscapular region.

Dysphagia and chest pain are easily provoked by mental trauma and psycho-emotional stressful situations.

Pain, like dysphagia, can be associated with food intake, but often occurs regardless of food and sometimes reaches the intensity of a pain crisis.

Heartburn and belching of air and eaten food are often noted. These symptoms may be due to hyperkinesia and hypertonicity of the stomach.

With a pronounced clinical picture of cardiospasm, a significant weight loss of the patient is observed, since patients eat little and rarely for fear of increased pain.

The diagnosis of cardiospasm is facilitated by fluoroscopy of the esophagus. In this case, a spasm of the lower esophageal sphincter is detected. On an x-ray of the esophagus, its outline becomes wavy, and retractions appear on its contours.

« Nutcracker esophagus"(synonym segmental spasm of the esophagus, English " nutcracer esophagus") - a violation of esophageal motility, in which contractions of the distal part of the esophagus are observed with high amplitude and long duration while maintaining the normal tone of the lower esophageal sphincter and its reflex opening during swallowing. A variant of esophageal spasm, characterized by hyperkinetic contractions.

“Nutcracker esophagus” is the most common esophageal dysfunction in patients who have chest pain not related to cardiac function. The diagnosis of “nutcracker esophagus” is established using esophageal manometry (the average pressure during 10 acts of swallowing liquid is above 180 mm Hg).

Nutcracker esophagus is characterized by high-amplitude peristalsis (180 mmHg) associated with chest pain or dysphagia, but the correlation between symptoms and manometry findings is not consistent. After some time, this condition resolves or turns into a diffuse spasm. Often accompanied by attacks of depression, anxiety and somatization (Harrison Handbook of Internal Medicine).

In case of “nutcracker esophagus”, a mandatory criterion for manometric diagnosis is an increased amplitude of distal contractions of the esophagus (>180 mm Hg). Optional signs include the possibility of lengthening the contraction time >6 s. On a manogram, contractions may also appear as multi-peak curves. The resting pressure of the lower esophageal sphincter can be either normal or increased. The sphincter may not fully open during swallowing (Storonova O.A. et al.).

Figure 1. Radiograph and results esophagomanometry with segmental spasm of the esophagus. The amplitude of contractions is high (>180 mm Hg), the peristaltic wave is multi-peaked. Duration of contractions >6 s (Storonova O.A. et al.).

Treatment of the “nutcracker esophagus”

Nutcracker esophagus is a benign, non-progressive disease that does not lead to serious complications.

Treatment at the first stage is medicinal, with calcium channel blockers (diltiazem, etc.). Sometimes therapy with sedatives is successful, especially in patients with a pronounced psychological component of the disease. Explaining to the patient the mechanisms of pain often gives positive results. After psychotherapy sessions, the frequency of pain attacks decreases. Myotomy is effective, but due to possible complications it is recommended only for severe cases of the disease.

Digestive system >>>> Nutcracker's Esophagus

The Nutcracker's esophagus.

The Nutcracker's esophagus, or the generally accepted name in the medical literature - segmental esophagospasm (from the Latin "oesophagus" - esophagus), is one of the esophageal dyskinesias, or more precisely, hypomotor dysfunction of the esophagus. In modern literature one can find another name for segmental esophagospasm - Barsoni-Taschendorff syndrome ( "beaded esophagus" from the word “rosary”). This name was inspired by its author by the appearance of segmental esophagospasm seen on an x-ray.

Regarding the inclusion of this disease in the group functional diseases of the esophagus There is an opinion that esophageal dyskinesias are persistent disorders of esophageal motility (there are also unstable, transient spasms of the esophagus, which can be observed in healthy people during stress or swallowing poorly chewed food in large pieces).

The causes of the Nutcracker esophagus have not yet been fully studied, but we can say with confidence that the development of this disease is observed against the background of certain diseases: peptic esophagitis, hiatal hernia, parkinsonism, bronchial asthma and others.

There is also an opinion that the causes of segmental esophagospasm are a consequence of psychosomatic disorders: depression, hysteria. And finally, persistent esophagospasm can be the result of short-term but periodic nervous shocks.

Significant advances in the analysis of the causes of Nutcracker esophagus and other hypomotor esophageal disorders were influenced by the discovery of certain biologically active substances of a hormonal nature. Endorphins, enkephalins, somatostatin, thyrotropin and other substances were found in brain tissue, which were also identified in the organs of the digestive system. This allowed us to talk about the existence of a certain cellular information system - Feirter’s diffuse endocrine system (it is also called: “APUD – Peirce system”). That is, a direct endocrine connection between the central nervous system and the digestive system was actually discovered.

The essence esophagospasm- This is a violation of peristalsis of the esophagus in its different parts. When they talk about segmental esophagospasm, they mean that disruptions in peristalsis occur in small areas of the esophagus (segments), and not along its entire length. The amplitude of vibrations of the esophageal wall in these areas increases (more than 180 mm Hg). There can be many such segments, and then they talk about multiple segmental contractions, but these contractions are stable. Such disruptions allow the food bolus to move forward, but the person experiences pain.

Nutcracker esophagus symptoms.

Dysphagia (impaired swallowing) - food passes, but pain occurs.
Feeling of heaviness behind the sternum.
Substernal pain (not typical) - radiates to the shoulder, neck, epigastric region and even to the lower jaw; may disappear when drinking warm liquid.
Heartburn, belching, vomiting are observed with a combination of segmental spasm of the esophagus and insufficiency of the cardia (esophageal sphincter muscle) of the esophagus.
May be asymptomatic (20% of cases).

Diagnosis of esophageal spasm.

Diagnosis of the Nutcracker esophagus is carried out in two directions: firstly, differential diagnosis is carried out with diseases that have similar symptoms, for example, angina pectoris. There are cases when chest pain occurs in the morning and is easily relieved with nitroglycerin, which misleads the doctor. There are cases when angina pectoris begins against the background of esophageal spasm (that is, it develops according to the type of viscero-visceral reflexes). In these cases, it is possible to exclude angina pectoris only with the help of thorough instrumental studies, which constitute the second direction in the diagnosis of esophageal spasm.

Hardware diagnostics include:

X-ray of the esophagus, which reveals spastic contractions of areas of the esophagus and makes it possible to visualize them.
Endoscopy of the esophagus to exclude organic changes in the tissues of the esophagus causing dysphagia.
Esophageal manometry to analyze the nature of spastic movements of the esophageal wall.
Ultrasonic diagnostics of the esophagus, which examines the motor and sensory functions of the esophagus and makes it possible to differentiate segmental esophagospasm from diffuse one.

Treatment of the Nutcracker esophagus.

The essence treatment of esophageal spasm is symptomatic and boils down to the following:

Relieving smooth muscle spasms or reducing the amplitude of oscillations and relieving pain:

Taking warm liquids
Antispasmodics.
Cholinomimetic and anticholinesterase agents.

When esophageal hypomotor dyskinesia is combined with insufficiency of the lower esophageal sphincter, antispasmodics and anticholinergic blockers are not used, since these drugs increase gastroesophageal reflux.

Calcium channel blockers.
Nitrates do not help in all cases.
Botulinum toxin injections (temporary effect).
Proton pump inhibitors (when combined with gastroesophageal reflux.
Sedatives and antidepressants (in difficult cases).

Organizing proper meals:

Crushing and chewing food thoroughly
Alternating dry foods with liquids during meals
Leisurely eating
While eating, do not be distracted by watching a movie, reading a book, or talking.

Complications and prognosis of segmental spasm of the esophagus.

Complications of dyskinesia are considered in the form of the development of other diseases of the esophagus: hypermotor disorders of the esophagus, hiatal hernia, esophageal diverticula, esophageal strictures. But with targeted and persistent treatment, the prognosis is considered favorable if esophageal dyskinesia did not initially have concomitant diseases (in this case, concomitant diseases are treated in parallel).

>>>> Nutcracker's Esophagus