Esophageal dyskinesias

Esophageal dyskinesia is a disorder of its motor (movement) function, consisting of a change in the movement of food from the pharynx to the stomach in the absence of organic lesions of the esophagus.

Disturbances in the motor function of the esophagus lead either to a delay or slowdown in the antegrade movement of food, or to the appearance of its retrograde movement.

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Classification of esophageal dyskinesia

I. Disorders of peristalsis of the thoracic esophagus

1. Hypermotor

• Segmental esophageal spasm ("nutcracker esophagus")
• Diffuse esophageal spasm
• Non-specific movement disorders

2. Hypomotor

II. Disorders of sphincter activity

1. Lower esophageal sphincter

Cardiac insufficiency:

• Gastroesophageal reflux disease
• Achalasia of the cardia
• Cardiospasm

2. Upper esophageal sphincter

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Hypermotor disturbances of peristalsis of the thoracic esophagus

Hypermotor dyskinesia of the thoracic esophagus is characterized by increased tone and motility, and this can be observed not only during swallowing of 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 typical that dysphagia is not constant, it can appear and disappear again during the day, it can be absent for several days, weeks, months and then appear again. Dysphagia can be provoked by smoking, food that is too hot or too cold, hot spices and sauces, alcohol, psycho-emotional stress situations;
• chest pain - occurs suddenly, can be quite intense, can radiate to the left arm, shoulder blade, half of the chest and, naturally, requires differential diagnosis with coronary heart disease. Unlike coronary heart disease, there is no connection with physical activity and there are no ischemic changes in the ECG;
• the sensation of a “lump in the throat” - occurs when the initial sections of the esophagus spasm and is more often observed in neuroses and hysteria;
• serration of the esophagus contours, local deformation and retention of the contrast mass in any part of the esophagus for more than 5 s (during fluoroscopy of the esophagus).

Segmental esophageal spasm ("nutcracker esophagus")

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

• dysphagia - characterized primarily by difficulty in passing semi-liquid food (sour cream, cottage cheese) and food rich in fiber (fresh bread, fruits, vegetables); dysphagia may occur when drinking 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 esophageal walls lasting more than 15 s with an amplitude of 16-18 mm Hg (according to esophagotonokimography)

Diffuse esophageal spasm

Characteristic manifestations of diffuse esophageal spasm are:

• extremely severe pain in the sternum or epigastrium, quickly spreading upwards and radiating along the anterior surface of the chest, to 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 lesswhen eating 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 (during X-ray examination of the esophagus);
• spontaneous (not associated with swallowing) contractions of the esophageal wall of high amplitude (more than 40-80 mm Hg) at a distance of more than 3 cm from each other (according to esophagotonokimography).

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Non-specific motor disorders of the esophagus

Non-specific disturbances of the motor function of the esophagus occur against the background of its preserved peristalsis.

The main symptoms are as follows:

• periodic occurrence 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, can go away on its own or after taking antacids or a sip of water;
• Dysphagia is rare.

On 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 of the 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 , a dotation test with inflation of a rubber balloon in the esophagus under esophagotonokimographic, radiological, electrocardiographic control (the test provokes the appearance of hypermotor dyskinesia of the esophagus).

Hypomotor disturbances of peristalsis of the thoracic esophagus

Primary hypomotor disturbances of esophageal peristalsis are rare, mainly in elderly and senile individuals and chronic alcoholics. They may be accompanied by cardia insufficiency and play a role in the development of reflux esophagitis.

About 20% of patients with hypomotor dyskinesia of the esophagus do not present any complaints. The remaining patients may have the following manifestations of the disease:

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

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 identify it with achalasia of the cardia. Well-known specialists in the field of gastroenterology A. L. Grebenev and V. M. Nechayev (1995) consider cardiospasm as a rather rare type of esophageal spasm 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 sensation of a "lump" in the throat, difficulty in passing food through the esophagus ("food gets stuck in the throat"). Later, the sensation of a foreign body in the esophagus bothers patients not only during meals, but also outside of meals, especially when worried. Very often, patients refuse to eat due to fear of intensifying these sensations. Dysphagia is often accompanied by increased respiratory rate, complaints of shortness of breath. With a significant increase in respiratory rate, choking on food is possible.

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, belching of air, food eaten are often noted. These symptoms may be caused by hyperkinesia and hypertonicity of the stomach.

In the case of severe clinical symptoms of cardiospasm, significant weight loss is observed in the patient, since patients eat little and rarely due to fear of increased pain.

Diagnosis of cardiospasm is facilitated by fluoroscopy of the esophagus. In this case, spasm of the lower esophageal sphincter is revealed. On the esophagus radiograph, its outlines become wavy, and retractions appear on its contours.

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Achalasia of the cardia

Achalasia of the cardia is a neuromuscular disease of the esophagus, consisting of a persistent impairment of the reflex of opening the cardia during swallowing and the appearance of dyskinesia of the thoracic esophagus.

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