Gastric cardia insufficiency

The esophagus enters the stomach in its cardiac part - in the zone of gastroesophageal (gastroesophageal) transition, and here is also located the lower esophageal or cardiac sphincter, also called gastric cardia (ostium cardiacum). Its dysfunction is defined as gastric cardia insufficiency.

Epidemiology

Gastroenterologists consider transient relaxation of the cardia as the main mechanism of acid reflux in at least 50% of healthy people, and in diagnosed gastroesophageal reflux disease - in 75% of patients (with a prevalence of GERD almost 3800 people per 100 thousand adults, according to WHO).

GERD is one of the most common gastrointestinal diseases, affecting approximately 20% of adults in Western culture. A systematic review by El-Serag et al. Estimated the prevalence of GERD in the United States from 18.1% to 27.8%. [1], [2] The prevalence of GERD is slightly higher in men than in women. [3] A large meta-analysis study by Eusebi et al.estimated that the cumulative prevalence of GERD symptoms was slightly higher in women compared to men (16.7% (95% CI 14.9% to 18.6%) vs. 15.4% (95% CI 13.5% to 17.4%). [4]

Achalasia cardia, on the other hand, is a fairly rare chronic disorder of lower esophageal sphincter function, with an incidence of 2.92 per 100,000 adults and 0.11 per 100,000 children, with a male-to-female ratio of approximately 1:1. [5], [6]

Causes of the gastric cardia insufficiency

The gastric cardia, the lower esophageal sphincter (LES), which is a muscular ring around the opening between the esophagus and the stomach, has two essential functions: to allow the bolus (food balloon) to enter the stomach by relaxation, and by contraction to close this opening, preventing retrograde movement of gastric contents (back into the esophagus), i.e. Gastroesophageal (gastroesophageal) reflux.

At rest in a healthy person, the muscular ring remains closed (the NPS is closed), and only after swallowing and the esophageal peristaltic wave caused by it, the muscles reflexively relax. However, as soon as the food lump enters the stomach, the ostium cardiacum closes.

Functional insufficiency of the gastric cardia is a disorder of its closing mechanism, which provides unidirectional passage of food into the stomach. It consists of a decrease in tone with relaxation of the muscular ring in the absence of swallowing, that is, the opening between the esophagus and the stomach remains partially or completely open. This condition in gastroenterology is most often defined as transient relaxation of the lower esophageal sphincter, spontaneous relaxation or atonic relaxation of the NSS.

In addition, there is an opposite type of lower esophageal sphincter failure - achalasia of the cardia. In this case, there is abnormally increased muscle tone of the sphincter with inability of its reflex relaxation, which leads to esophageal dyskinesia and food retention there. This insufficiency of the lower esophageal sphincter is associated with disorders of innervation of the esophagus (although the version of autoimmune nature of the disorder is considered). All details in the publication - Causes of achalasia of the cardia

Abnormal relaxation of the NPS with transient nonclosure of the cardiac orifice has a variety of causes. First of all, experts note a high probability of vagotonic type of esophageal innervation disorders - vagus nerve (nervus vagus). There may also be partial dysfunction of the motoneurons of the Auteurbach's plexus, the intermuscular nerve plexus (plexus myentericus), which is part of the enteric (intestinal) nervous system.

The association of this type of cardia insufficiency with such diseases and pathologic conditions as:

• gastroptosis (stomach prolapse);
• abdominal bloating, which is accompanied by gastritis with hyperacidity;
• Esophageal hiatus hernia (hiatus oesophageus) - sliding or axial hernia of the esophagus, in which the stomach may prolapse into the esophagus or gastroesophageal prolapse - prolapse of a small part of the mucosa lining the stomach, adjacent to the cardiac opening.

Insufficiency of the gastric cardia rosette - folds of the mucosa at the gastroesophageal transition from the gastric glandular epithelium to the esophageal squamous cell epithelium - lies in its reduced protection of the lower esophagus from the aggressive effects of gastric acid. Such a condition may be observed if there are highly located (subcardiac) focal erosive gastritis or peptic ulcer disease with predominant localization in its cardiac or fundal parts.

Risk factors

Risk factors for transient relaxation of the cardia include gastroenterologists:

• Constant overeating (leading to stomach distension);
• high-fat intake;
• Elevated nitrate and nitrite levels in food;
• overweight;
• smoking and excessive alcohol consumption;
• increased pressure in the abdominal cavity (including due to physical overload);
• delayed gastric emptying, such as in functional dyspepsia or gastroparesis - lazy stomach syndrome;
• Diabetes mellitus (which can be complicated by gastrointestinal neuropathy and provoke esophageal dyskinesia).

Also, impaired closure of the cardia may be secondary to polymyositis and dermatomyositis or systemic scleroderma (connective tissue disease).

In addition, there are iatrogenic risk factors, since as a side effect, regularly used drugs can induce a decrease in NPS tone: psychotropic, sedatives and sleeping pills; Nitroglycerin; hypertension and cardiac arrhythmia agents (belonging to the pharmacological group of calcium antagonists); bronchial dilating β2-adrenomimetics; anti-ulcer drugs - proton pump inhibitors.

Pathogenesis

The development of NPS insufficiency has a very complex and not yet fully understood pathophysiologic mechanism due to the reactions of myocytes of circular smooth muscles of the cardiac region of the stomach and their autonomic innervation.

Under normal conditions, the gastric cardia is in a state of tonic contraction when not eating. Its spontaneous relaxation may be caused by a decrease in pressure at the gastroesophageal junction compared with intragastric or intra-abdominal pressure. In addition to the consumption of fats and alcohol, the decrease in NPS pressure and its transient relaxation are due to weakening and discoordination of the diaphragm legs, the divided extensions of the inferior diaphragmatic fascia (fascia inferior diaphragmatis), which attach at the site of the esophageal opening of the diaphragm (hiatus oesophageus) and contract with the gastric cardia. The pressure of the cardia may also decrease if the ligamentum phrenoesophageale (ligamentum phrenoesophageale), which anchors the esophagus, is weakened, which is often seen in the elderly.

The muscular lining of the esophageal wall has circular (inner) and longitudinal (outer) layers, which normally contract synchronously during peristalsis.

As a result of motility disorders, the longitudinal muscle layer begins to contract independently of the circular muscle layer; its contractions are longer and stronger than those of the inner muscle layer. Asynchronous contractions of the muscle layers of the esophageal wall lead to displacement of the cardiac sphincter and its spontaneous relaxation, unrelated to food intake.

With regard to innervation of the NPS, there is activation of intramuscular inhibitory motoneurons of the intermuscular nerve plexus with release of the neurotransmitter nitric oxide, which, penetrating through the cell membranes of myocytes, mediates relaxation of muscle fibers of the NPS due to afferent signals of the vagus nerve.

See also - Gastroesophageal reflux disease (GERD) - Pathogenesis

About the pathogenesis of achalasia of the cardia, which is explained by damage and reduction in the number of ganglionic neurons of the intermuscular nerve plexus. Read more in the article - Causes of achalasia of the cardia

Symptoms of the gastric cardia insufficiency

When the tone of the gastric cardia is reduced and its incomplete closure (outside swallowing), the first signs are manifested in the form of frequent belching (air or food).

Other symptoms include heartburn - burning in the throat, burning sensation in the sternum; increased salivation; and dry cough.

In cases of transient spontaneous relaxation of NPS with retrograde movement of gastric contents causes gastric cardia insufficiency gastric pain behind the sternum of burning character. In horizontal and inclined positions of the body the pain increases.

And increased tone of the lower esophageal sphincter with a violation of its reflex relaxation begins to manifest itself with a feeling of stuck food (almost all patients complain of a "lump in the throat"), dysphagia - difficulty swallowing and regurgitation of undigested food. Full information in the materials:

• Symptoms of achalasia of the cardia
• Types of cardia azalasia

There are three degrees of transient relaxation of the cardiac sphincter. With its incomplete closure (the opening between the esophagus and stomach remains open by about 30%) is defined I degree; non-closure of 50% ostium cardiacum means II degree; at III degree the sphincter is almost completely open outside swallowing.

Complications and consequences

What are the dangers of gastric cardia insufficiency? Prolonged presence of achalasia of the cardia can cause nutritional disorders and significant weight loss; damage to the mucosa of the distal esophagus - stagnant esophagitis; esophageal dilation (with thinning of its wall); formation of diverticula; aspiration pneumonia. There is also an increased risk of endophytic esophageal squamous cell cancer.

Consequences of transient relaxation of the cardiac sphincter include:

• Gastroesophageal reflux disease (GERD),
• esophageal erosion,
• Reflux esophagitis or erosive esophagitis,
• peptic esophageal stricture,
• intestinal metaplasia - Barrett's esophagus (with a high probability of malignant transformation of mucosal cells).

Diagnostics of the gastric cardia insufficiency

To detect gastric cardia insufficiency, a examination of the esophagus and its function is performed. First of all, a patient history and an assessment of the patient's present complaints and symptoms are necessary.

Instrumental diagnostics are used: contrast esophagography (X-ray with barium), ultrasound of the gastrointestinal tract, esophageal endoscopy, EGDS - esophagogastroduodenoscopy, esophagomanometry (intraesophageal manometry), esophageal pH-impedanceometry.

Laboratory tests include general and biochemical blood tests, breath test for Helicobacter pylori, determination of the level of acidity of gastric juice (using intragastric pH-metry).

Endoscopic signs of functional insufficiency of the gastric cardia consist in asymmetry of the lower esophageal sphincter and esophagus - with displacement of muscle fibers of the circular layer of the cardiac part of the stomach. In achalasia of the cardia, dilation and tortuosity of the esophagus, hyperemia of its mucosa are distinguished. The NPS is closed even with insufflation (pumping carbon dioxide into the esophagus to increase its lumen), but when the endoscope is pressed, the opening between the esophagus and the stomach opens.

Differential diagnosis is done to rule out other causes of heartburn and difficulty swallowing.

Also see: Diagnosing Achalasia of the Cardia

Treatment of the gastric cardia insufficiency

There are no selective drugs that can increase or decrease the tone of the lower esophageal sphincter. And in case of transient relaxation of the cardiac sphincter, the main drugs belong to the pharmacological group of prokinetics (stimulating propulsive gastrointestinal peristalsis): Metoclopramide, (other trade names are Metamol, Cerucal, Gastrosil, Reglan; Itopride, Itomed or Ganaton; Domperidone (Peridone, Motilium, etc.); Motapride (Mosid MT); Bethanechol.

And for heartburn take antacids: Almagel, Rennie, Phosphalugel, Maalox. Also to relieve heartburn can help treatment with herbs using: chamomile (flowers), licorice (root), leaves of peppermint and lemon balm, bird's throat, medicinal beechgrass.

In case of gastric cardia insufficiency with impaired reflex relaxation of the sphincter, a cardiac drug (peripheral vasodilator) Isosorbide dinitrate (other trade names - Izodinit, Iso-mik, Nitrosorbide, Cardiket, Dicor) is used.

Read more in the publications:

• Treatment of achalasia of the cardia
• Gastroesophageal reflux disease (GERD) - Treatment

Is surgery for gastric cardia insufficiency? Yes, surgical intervention is possible in both types of cardia insufficiency. While laparoscopic myotomy of the gastroesophageal junction according to Heller can be performed for achalasia, surgical treatment of atony and transient relaxation of the NSS involves Nissen fundoplication, an operation in which the bottom of the stomach is wrapped around the esophagus to create a cuff that prevents gastroesophageal reflux.

Read also - Gastroesophageal Reflux Disease (GERD) - Surgical Treatment

As a rule, the diet for gastric cardia insufficiency - the optimal menu (with the exclusion of foods that can worsen the symptoms), the correct diet during the day (what is better to eat for breakfast, lunch and dinner) is based on heartburn diet or similar in principles reflux esophagitis diet.

Although the gastric cardia is a muscular sphincter, therapeutic exercises can be effective if functional failure of the NPS is associated with gastric prolapse. Then it is recommended to perform exercises for gastric prolapse.

Prevention

There are no specific measures for the prevention of functional insufficiency of the gastric cardia. General recommendations relate to compliance with the principles of a healthy lifestyle, a rational diet and weight control. More information in the article - Prevention of achalasia

Forecast

In the case of functional insufficiency of any organ, the prognosis is directly related to its degree, its impact on other systems, the intensity of symptoms and the results of treatment. Insufficiency of the lower esophageal sphincter negatively affects the digestive system and the gastrointestinal tract, significantly worsening the general state of health.

Gastric cardia insufficiency and the army: there is no such diagnosis in the officially approved List of diseases, conditions and physical disabilities that determine the degree of fitness for military service. But suitability for military service is determined individually, and if esophagitis or gastroesophageal reflux disease does not lead to impaired function, the conscript is considered to be of limited fitness.

Literature

Ivashkin, V. T. Gastroenterology. National guide / ed. By V. T. Ivashkin, T. L. Lapina - Moscow : GEOTAR-Media, 2018. - 464 с.