Treatment of achalasia of cardia

Treatment of achalasia cardia has several purposes:

Elimination of the functional barrier for passage of food in the form of an unrestricted lower esophageal sphincter and preventing the development of complications of the disease.

The most effective are pneumocarditis and cardiomyotomy. Drug therapy has an auxiliary significance.

Indications for hospitalization

Treatment of achalasia of cardia is carried out under stationary conditions.

Urgent hospitalization is necessary

• when it is impossible to take food through the mouth;
• with the development of aspiration pneumonia and the need for intravenous antibiotics or artificial ventilation (IVL).

Indications for specialist consultation

Occur if surgical treatment is necessary: the actual achalasia is the surgeon; complications in the form of a tumor of the esophagus - an oncologist. If parenteral nutrition is necessary, it is advisable to consult an expert in nutritional therapy.

Non-pharmacological treatment of achalasia of the cardia

Mode

Restriction of loads: physical, especially abdominal muscles, psychological (sleep not less than 8 hours / day).

Diet

Patients with achalasia of the cardia should follow a certain diet and special recommendations regarding the intake of food.

Immediately after eating, avoid the horizontal position of the body; during sleep, a strictly horizontal position of the body is also not shown, since food can stay in the esophagus for up to several hours, and the upper esophageal sphincter relaxes during sleep, which creates the prerequisites for aspiration. Take food slowly, thoroughly chewing it.

Food should not be too cold or hot, the diet should exclude foods that can exacerbate dysphagia in specific patients.

It should be borne in mind that the amount of food should not be excessive, as overeating leads to a worsening of the patient's condition. It is recommended to observe four or five meals a day.

[1], [2], [3]

Cardiodilation

The most common and effective method of treating cardiac achalasia. The essence of the method consists in the forced expansion of the lower esophageal sphincter with a balloon into which air or water is injected under high pressure.

Indications for cardiodilation:

• the first identified achalasia of cardia of types I and II; relapse after cardiac surgery.

Cardiac surgery for cardiac achalasia is not indicated in the following situations.

• Noncorrectable disorder of blood coagulability. Concomitant varicose veins of the esophagus or its stricture.
• Ineffectiveness of three-time cardiodilation. Presence in the anamnesis of perforation of the esophagus after cardiodilation.
• The presence of concomitant diseases that significantly increase the risk of surgical treatment (since cardiodilation can lead to esophageal perforation, which will require prompt treatment).
• The probability of perforation of the esophagus during its pneumocarditisation is about 3%.
• In cases of significant curvature of the esophagus, a technique for endoscopic cardiodilation has been proposed.

[4], [5], [6]

Application of botulinum toxin

Other methods for lowering the tone of the lower esophageal sphincter include intramural injection of botulinum toxin or sclerosants into the lower esophageal sphincter of botulinum toxin or sclerosants (for example, 1% sodium tetradecyl sulfate solution, 5% ethanolamine oleate solution, 5% sodium morruate solution, 1% ethosclerol solution) with an endoscopic needle. Botulinum toxin is administered at a dose of 50-100 ED directly into the lower esophageal sphincter region. Repeated procedures for the administration of the drug are necessary. The introduction of botulinum toxin is of limited importance: only 30% of patients after endoscopic treatment do not experience dysphagia. Endoscopic methods of treatment of achalasia are indicated to patients who are not able to perform cardiodilation and cardiomyotomy.

[7], [8], [9], [10], [11], [12], [13]

Medicinal treatment of achalasia of cardia

The most effective medicines are calcium channel blockers and nitrates. Indications for their use are as follows:

• The need to relieve symptoms before cardiodilation or cardiomyotomy.
• Ineffectiveness or incomplete effect of the use of other methods of treatment.
• The presence of severe concomitant diseases, excluding the possibility of cardiac surgery or cardiomyotomy.

The drugs used:

Nitrendipine in a dose of 10-30 mg 30 minutes before meals sublingually. Isosorbide dinitrate in a dose of 5 mg for 30 minutes before meals sublingually or at a dose of 10 mg orally.

Surgical treatment of achalasia of cardia

Cardiomyotomy

The myotomy of the lower esophageal sphincter region is carried out - cardiomyotomy. Indications for its conduct: the first identified achalasia of cardia I and II types; relapse after cardiac surgery.

[14], [15], [16], [17], [18], [19], [20]

Contraindications

• The presence of concomitant diseases, which significantly increase the risk of surgical treatment.
• Noncorrectable disorder of blood coagulability.
• The presence of varicose-dilated esophagus veins.

Usually, cardiomyotomy is performed by open access, but in recent years, the endoscopic approach to cardiomyotomy has become widespread. Apply both laparoscopic and thoracoscopic techniques. It is recommended to combine cardiomyotomy with fundoplication to prevent pathological gastroesophageal reflux.

[21], [22], [23], [24], [25], [26]

Gastrostomy

It is necessary to consider the possibility of imposing gastrostomy for the patient's nutrition, when the inactive treatment is ineffective, and the risk of a surgical approach is high.

Esophagectomy

One should consider the possibility of esophagectomy with inefficiency of any other treatment for achalasia of the cardia, and also in the presence of operable esophageal cancer. Esophagectomy followed by plasty of the esophagus is indicated in the following situations.

Ineffectiveness of adherence to dietary recommendations, drug therapy, cardiodilatapy and surgical treatment with an unacceptable quality of life of the patient due to severe manifestations of cardiac achalasia.

The development of persistent manifestations of gastroesophageal reflux disease or its complications, in the treatment of which the medical and surgical methods proved to be ineffective, and the patient's quality of life is unacceptably low. The development of esophageal cancer provided it is operable

[27], [28], [29], [30], [31], [32]

Treatment of cardiac achalasia complications

If you can not eat through the mouth, the following activities are shown:

• Intravenous administration of fluids to correct dehydration and electrolyte disorders, often occurring in such patients.
• Intravenous administration of drugs, the introduction of which through the mouth is impossible.
• Aspiration of esophagus contents through the naso-oesophageal probe to prevent regurgitation and vomiting of swallowed saliva.
• Complete parenteral nutrition, if radical medical measures need to be postponed for several days. When perforating the esophagus due to cardiodilation, the following measures are necessary.
• Emergency surgeon consultation (usually an open procedure is performed, although there are reports of successful laparoscopic treatment).
• Aspiration of esophagus contents through the naso-oesophageal probe to prevent regurgitation and vomiting of swallowed saliva.
• Intravenous administration of fluids to correct dehydration and electrolyte disorders, often occurring in such patients.
• Parenteral administration of broad-spectrum antibiotics directed primarily against oral microflora.
• Parenteral administration of narcotic analgesics in severe pain syndrome.

Further management of the patient

Observation of a patient with achalasia of cardia is carried out in a specialized hospital.

Events

Patient's questioning: assessment of the progression of the disease and its rate. Frequency 1 every 6-12 months.

Physical examination: detection of signs of complications of achalasia - aspiration pneumonia, esophageal cancer. Frequency 1 every 6-12 months.

Laboratory examination: a general blood test, a general urine test, blood albumin content . Frequency if necessary, if suspected of insufficient nutrient intake into the body due to achalasia.

Instrumental examination (PHAGS, radiography): evaluation of the progression of the disease and its rate, timely detection of complications of the disease. Frequency 1 every 6-12 months or if necessary in the presence of characteristic clinical manifestations.

In addition, it is necessary to identify the possible side effects of the drugs used, if necessary, for their long-term use.

[33], [34], [35],

Criteria for evaluating therapy

• Recovering - the complete disappearance of dysphagia, the normalization of the passage of contrast medium through the esophagus into the stomach during X-ray examination serve as criteria for the effectiveness of the treatment of achalasia of the cardia.
• Improvement - a significant reduction in the signs of dysphagia, a slight delay in passing the contrast medium through the esophagus into the stomach during X-ray examination.
• Without changes - the preservation of dysphagia, the previous radiographic picture, the absence of the reflex of opening the lower esophageal sphincter in carrying out intra-esophageal manometry.
• Deterioration is an increase in dysphagia, the appearance of signs of dehydration, ketonuria, the association of pulmonary complications (pneumonia).

[36], [37], [38], [39], [40], [41], [42]

Patient education

The patient must provide full information about upcoming medical events.

The patient should be informed that the positive effect of treatment is not observed in all patients, i.e. There can be a situation when the conducted measures will not lead to the relief of the patient's condition.

The patient should understand that the disappearance of the manifestations of the disease under the influence of ongoing therapy does not mean a complete cure, so it is necessary to continue compliance with medical recommendations.

The patient should be cautioned against the use of tableted dosage forms containing substances that are capable of damaging the esophageal mucosa:

• Acetylsalicylic acid (including small doses necessary for the prevention of vascular accidents);
• non-steroidal anti-inflammatory drugs (NSAIDs), even with an enteric-soluble coat;
• ascorbic acid;
• ferrous sulphate;
• potassium chloride;
• alendronate;
• doxycycline;
• quinidine in the form of sustained-release tablets.

If you can not refuse the use of these drugs, they should be washed down with a glass of water and taken in standing position. The patient should be informed of the manifestations of cardiac achalasia complications, so that when they develop, he can seek medical help on time.

Disability

Work ability is not disrupted until the dysphagia is only temporary, or appears with a certain food and it can be overcome by appropriate diet adjustment or drinking, until the food decreases, the esophagus is enlarged and esophagitis is not too intense. It is necessary to remember the importance of psychogenic factors in these lesions. If there are signs of a neurosis, then the conclusion is made with regard to them; this also applies to periodic spasms of the esophagus, which are almost always a neuropathic disorder.

For people with achalasia, work with mental stress and night shifts is not suitable, etc. Conservative treatment of achalasia of the cardia is appropriate to begin with the termination of work, during which the patient must rest, get used to the correct method of nutrition, ie, in a state of complete rest , in the absence of physical and mental stress and apply sedative and spasmolytic treatment.

If there is more severe dysphagia, a constant, for all dense nutrients, weight loss, esophageal expansion, more severe concomitant esophagitis with congestion or pulmonary complications, it is appropriate to establish disability for a treatment period that can be either expansive or operative. In case of negative result or impossibility of active treatment, the patient is transferred to a disability (complete), regardless of the type of work.

[43], [44], [45], [46], [47]