Dysphagia in children: causes, symptoms, diagnosis, treatment

Dysphagia (violation of swallowing) - describe as a feeling of difficulty when swallowing liquid or thick food, regardless of the true causes and localization of the defect. This phenomenon is based on diseases of the perinepharyngeal muscle and proximal esophagus, due to the pathology of skeletal muscles. Among the violations leading to dysphagia can be identified:

• violation of the swallowing reflex;
• mechanical obstruction;
• violation of motor activity;
• gastroesophageal reflux.

Among the reasons for the violation of swallowing can be identified the following:

• neuromuscular diseases, which include congenital and acquired diseases of the central and peripheral nervous systems (vascular disorders, multiple sclerosis, Parkinson's disease, brainstem tumors, pseudobulbar paralysis, peripheral neuromyopathies: myasthenia gravis, poliomyelitis, dermatomyositis);
• mechanical obstruction caused by an increase in the thyroid gland, lymphadenopathy, oropharyngeal carcinoma, congenital defects, inflammatory diseases, hyperostosis of the vertebrae of the cervical spine;
• iatrogenic defects associated with surgical manipulations in the oropharynx, radiotherapy, damage to the cranial nerves innervating the oropharynx.

Among the main clinical symptoms of swallowing disorders are the following:

• oropharyngeal dysphagia of liquid and solid foods;
• oropharyngeal dysphagia with primary disturbance of the reflex mechanisms of the swallowing act (often combined with speech disorders, language paresis and pulmonary aspiration);
• nasopharyngeal regurgitation.

Differential diagnosis should be performed with achalasia of the peronephricnus muscle, gastroesophageal reflux and senker diverticulum. Diagnosis is based on fluoroscopic data with barium, video-radiography, endoscopy and video endoscopy analysis, manometry. 

Sencer's diverticulum.

The diverticulum of the senker is a hernia of the pharyngeal mucosa on the border of the pharynx and esophagus. The diverticulum penetrates dorsally between the circular and oblique part of the pernneglogochnoy muscle. During the act of ingestion, food can enter the hernial sac before it enters the esophagus. This causes symptoms of dysphagia and regurgitation of undigested food from the diverticulum of the senker.

The cause of the development of the diverticulum of Zenker is unclear. Most likely, an important role is played by features of the anatomical structure. In addition, dysfunction of the superior esophageal sphincter, the upper part of the esophagus, may also play a role in the occurrence of the diverticulum of the countersink. Currently, there are two hypotheses that explain the appearance of the diverticulum of the sinker: a disruption in the precise coordination between the relaxation of the upper esophageal sphincter and contractions of the pharynx; violation of the opening of the upper esophageal sphincter, associated with fibrotic or degenerative changes in muscle fibers.

The clinical picture is characterized by regurgitation of undigested food, dysphagia, a feeling of raspiraniya and the neck, especially after eating, lack of appetite, coughing, attacks of suffocation, drooling. There is a difficulty in the passage of food in the cryopharyngeal region. Infringements are noted immediately after birth, during the first month of life and are mainly represented by ineffective reflex relaxation and pathologically high resting pressure of the upper esophageal sphincter. Low resting pressure of the upper esophageal sphincter is characteristic of the group of neuromuscular diseases - myasthenia gravis, poliomyelitis, muscular dystrophy, accompanied by an increased risk of aspiration of the contents of the esophagus. Violation of the process of relaxation of the upper esophageal sphincter involves an increase in the time of its relaxation, inefficiency, as well as premature closure. For cryopharyngeal achalasia, its incomplete relaxation is characteristic. In the pathogenesis of Zenker diverticulum, an important role is played by premature closure of the superior esophageal sphincter.

Differential diagnosis is carried out with diseases leading to disruption of swallowing, esophageal stricture and tumors.

Treatment includes a rational diet, pneumatic dilatation and myotomy. In case of a pronounced lag in development, it is possible to feed on a nasogastric tube (for a short time) or through a formed gastrostoma (long term). Dilation is indicated for children with cryopharyngeal achalasia and discoordination of this zone. To cryopharyngeal myotomy in case of disruption of the functioning of the superior esophageal sphincter should be resorted only in extreme cases.

Functional diseases of the esophagus

The importance of functional disorders of the esophagus in children's gastroenterology is determined by their frequency and prevalence. They are formed during periods of the most intensive growth and functional organ ripening, when physiological processes are still unstable and easily prone to disorders, and functional disorders of the esophagus are more often observed in childhood and adolescence. Long-term functional disorders of motor activity of the esophagus often lead to morphological changes.

Disturbances in the motor activity of the esophagus are divided into primary, secondary and nonspecific.

Achalasia of the perinepharyngeal muscle. Achalasia is a fairly frequent violation of the activity of the superior esophageal sphincter, of which the constituent component is the pharyngeal muscle. This condition is due to the inadequate relaxation of the peronephricular muscle in response to food intake into the zone of the upper esophageal sphincter and the consequent difficulty in transferring food from the pharynx to the esophagus ("food is stuck in the pharynx"). It is difficult to pass both liquid and solid foods. Often, difficulties in the passage of food lead to popperhivaniyu, aspiration in the respiratory tract, patients are afraid to eat and quickly lose weight. The disease is often accompanied by the formation of pharyngo-esophageal diverticula, which are manifested by a loud rumbling in the neck when swallowing, regurgitation.

Dyskinesia of the esophagus hypertonic (esophagospasm, diffuse spasm of the esophagus, achalasia, cardiospasm, hiatuspasm). The multiplicity of names indicates a lack of consensus on the localization and nature of this form of esophageal dyskinesia. The diffusion spasm of the esophagus (DSP) is based on a primary impairment of the motor function of the lower 2/3 esophagus with the normal functioning of the proximal part, as a result of which cardiac relaxation is delayed after the swallowing act. Despite sufficient knowledge of this issue and even the creation of a biological model, up to the present time some clinicians have identified the concepts of esophagospaem and achalasia, while others, on the contrary, are divided into such nosological forms as mega-esophagus, local spasm, diffuse spasm.

Diffusive spasm of the esophagus is a polyethological disorder of its function. Most researchers believe that the cause of spasm of the esophagus is a violation of the neural-vegetative innervation of the body due to functional disorders of the nervous system (neurosis), mental trauma, etc. A certain role is played by heredity, general lack of exercise, the nature of nutrition, acceleration, and inflammatory lesions of the mucosa of the esophagus. When studying the ultrastructure of nerve fibers in the diffuse spasm of the esophagus, the presence of degenerative processes was shown in them, without affecting the nervous vegetative ganglia. The main link in the pathogenesis of diffuse spasm of the esophagus is the disruption, or deactivation, of a successive alternation of post-inflammatory peristaltic esophageal contractions. They are replaced by strong multi-amplitude spastic contractions, which sometimes cover significant parts of the esophagus and gradually lead to muscle hypertrophy. These non-refractory contractions are different in strength and duration. Instead of relaxing during the passage of food, there are muscle contractions: they appear outside the swallowing act and disappear with the next peristaltic wave. With diffuse esophagospasm, hyperplasia of the epithelium, parakeratosis, interstitial edema and cardio dilatation develop.

Despite the name of this functional disorder - "diffuse spasm of the esophagus," along the length of the spasmodic area, a widespread and localized form is distinguished . The localized form, as a rule, occurs in the middle or lower part of the esophagus. The greatest clinical significance is the spasm of the lower third of the esophagus, which can last from several minutes to several hours. The clinical picture is characterized by:

• pain in the esophagus with irradiation in the neck, hands, lower jaw;
• dysphagia;
• loneliness (painful swallowing).

Children usually complain of pain behind the sternum or epigastrium, a sense of constriction that occurs during a hasty meal. Painful sensations arise suddenly, sometimes in connection with negative emotions. A characteristic sign of dysphagia in diffuse spasm of the esophagus is the absence of previous nausea: the child suddenly becomes restless, jumps up, makes futile attempts to swallow a piece of food stuck in the esophagus. There may be cases of so-called paradoxical spasm of the esophagus. Spasm occurs when swallowing liquid food and even liquids, in particular cold water. Dysphagia can be accompanied by regurgitation. Pronounced and frequent regurgitation leads to loss of body weight. Long-existing spasm of the esophagus causes the expansion of the esophagus region above the spasmodic. In such cases, regurgitation becomes more rare, but much more abundant. Regurgitation at night can lead to pulmonary aspiration. Observed in adult patients such symptoms as dyspnoea, palpitation, in children, as a rule, absent.

Differential diagnosis is performed with gastroesophageal reflux disease (GERD), achalasia, scleroderma, carcinoma and coronary heart disease.

Diagnostic procedures include endoscopy, fluoroscopy, manometry.

Nonspecific disorders of esophageal motility. Rare syndromes. Esophagus "nutcracker" (syn: symptomatic esophagal peristalsis). In addition to the hypertonic form of dyskinesia of the esophagus or idiopathic diffuse esophagospasm, which is the most nosologically defined form of the functional pathology of the esophagus, there are other functional disorders of this organ. Two types of such disorders are described: the hypermotility form - hypertensive peristaltic contractions (the "esophagus of the nutcracker") and nonspecific motor disorders of the esophagus.

The etiology of the "nutcracker esophagus" and nonspecific motor disorders (HPM) is unknown. A number of authors consider it the debut of ahalasia. The connection with gastroesophageal reflux and stress was proved.

Symptomatic esophagal peristalsis or the "esophagus of the nutcracker" is the basis of the clinical syndrome, which is a phenocopy of angina pectoris in combination with dysphagia.

Disturbance of the esophagus motility is characterized by increased peristalsis (the radiologic pattern resembles the Nutcraker "Nutcraker" forceps) with a significant increase in strength and length of the peristaltic full. The diagnosis is based on the results of a manometric study, in which the pressure during the peristaltic wave reaches 200 mm Hg. Art. With a duration of more than 7.5 seconds.

Nonspecific movement disorders of the esophagus (rare syndromes)

• Mersjo-Kampa syndrome - segmental esophagus contractions that cause dysphagia "and pain behind the sternum.
• Barshton-Teschwindorf syndrome - multiple segmental spasms of the esophagus at different levels (esophagus of the azde of the pearl necklace), accompanied by bouts of painful dysphagia, regurgitation of the food and chest pain.
• The syndrome of dysphagia, the pain of the chest during swallowing and rest, a slight expansion of the esophagus and a delay in food over the cardia, caused by an increase in the tone of the lower esophageal sphincter (dyshalasia).
• Old Terracolla - dysphagia, hoarseness of voice, pain in the throat and behind the sternum with cervical osteochondrosis. One of the variants of the syndrome of "cervical migraine".
• Syndrome Barre-Lieu high dysphagia, due to neurovascular disorders of the cervical spine.
• Berci-Roshena syndrome - dysphagia with injuries of the cervical spine at the level of C4-Th1,
• Syndrome Geberden - Eagrudin pain and dysphagia in the pathology of the cervico-thoracic spine at the level of C4-T4.
• Larmitt-Monier-Wiener syndrome- spastic pharyngeal-esophageal dysphagia with vagotonia
• Mudzhiya syndrome - spasms of the esophagus, up to henia, with a violation of calcium metabolism (hypocalcemic dysphagia).
• Syndrome Kostshmya - high dysphagia, sore throat, tongue, caused by an incorrect bite.
• Hildzher's syndrome - neurovegetative swallowing disorders and pain in the nape of hemodynamic disorders in the carotid artery basin.
• Furia syndrome - severe pain behind the sternum, caused by spasm and stenosis of the cardiapause of the esophagus (cardia-cardial syndrome).
• Tipre-Riszert syndrome - achalasia of cardia in infants, manifested by dysphagia and regurgitation (perverted Neuhaus-Verenberg syndrome).

A clear division between nonspecific and primary disorders of esophageal motility (achalasia, diffuse spasm of the esophagus and esophagus of the "nutcracker") is often simply impossible. Many patients with HPM with dysphagia and retrosternal pain demonstrate various variants of esophagus cuts that do not fit into the criteria of primary esophageal motility disorders. They are treated as HPM. The table presents an attempt to present the HPM in the form of syndromes.

Unlike the group of secondary disorders of the motor function of the esophagus, the treatment of the above diseases is ineffective. Most clinicians offer nitrates, calcium channel blockers, hydralazine, as well as anticholinergic medications because of their relaxing effect on smooth muscles, as an initial therapy. It is possible to use psychotropic drugs to arrest stressful situations that aggravate and support motor disorders. However, a single pharmacological management tactics for these patients have not been developed to date. With unsuccessful drug treatment, bougie and pneumatic dilatation are used, and as an extreme option - eeophagomyotomy.

[1], [2], [3], [4], [5]