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Functional Hiatal Stenosis Hiatal Esophagismus Phrenospasm Diaphragmatic Pinchcock Stenosis

Category: DISEASES OF THE ESOPHAGUS
Source: A Manual Of Peroral Endoscopy And Laryngeal Surgery

There is no sphincteric muscular arrangement at the cardiac orifice of
the esophagus, so that spasmodic stenosis at this level is not
possible and the term cardiospasm is, therefore, a misnomer. It was
first demonstrated by the author that in so-called cardiospasm the
functional closure of the esophagus occurred at the diaphragmatic
level, and that it was due to the diaphragmatic pinchcock.
Anatomical studies have corroborated this finding by demonstrating a
definite sphincteric mechanism consisting of muscle bands springing
from the crura of the diaphragm and surrounding the esophagus at the
under surface of the hiatus. An inspection of the cadaveric diaphragm
from below will demonstrate an arrangement like double shears
admirably adapted to this pinchcock action. Further confirmation is
the fact that all dilatation of the esophagus incident to spasm at its
lower extremity is situated above the diaphragm. In passing it may be
stated that the pinchcock action, plus the kinking of the esophagus
normally prevents regurgitation when a man with a full stomach stands
on his head or inverts his body. For the upward escape of food from
the stomach an involuntary co-ordinated antiperistaltic cycle is
necessary. The dilatation resulting from phrenospasm may reach great
size (Fig. 96a), and the capacity of the sac may be as much as two
liters. While the esophagus is usually dilated, the stomach on the
other hand is often contracted, largely from lack of distention by
food, but possibly also because of a spastic state due to the same
causes as the phrenospasm. Recently Mosher has demonstrated that
hepatic abnormality may furnish an organic cause in many cases
formerly considered spasmodic.

The symptoms of hiatal esophagismus are variable in degree.
Substernal distress, with a feeling of fullness and pressure followed
by eructations of gas and regurgitation of food within a period of a
quarter of an hour to several hours after eating, are present. If the
esophageal dilatation be great, regurgitation may occur only after an
accumulation of several days, when large quantities of stale food will
be expelled. The general nutrition is impaired, and there is usually
the history of weight loss to a certain level at which it is
maintained with but slight variation. This is explained by the
trickling of liquified food from the esophageal reservoir into the
stomach as the spasm intermittently relaxes, this occurring usually
before a serious state of inanition supervenes. At times the hiatal
spasms are extremely violent and painful, the pain being referred from
the xiphoid region to the back, or upward into the neck. Patients are
often conscious of the times of patulency of the esophagus; they will
know the esophagus to be open and will eat without hesitation, or will
refuse food with the certain knowledge that it will not pass into the
stomach. Periods of remission of symptoms for months and years are
noted. The neurotic character of the lesion in some cases is evidenced
by the occasionally sudden and startling cures following a single
dilatation, as well as by the tendency to relapse when the individual
is subject to what is for him undue nervous tension. In a very few
cases, with patients of rather a stolid type, all neurotic tendencies
seem to be absent.

The diagnosis of hiatal esophagismus requires the exclusion of local
organic esophageal lesions. In the typical case with marked
dilatation, the esophagoscopic findings are diagnostic. A white,
pasty, macerated mucosa, and normally contracted hiatus esophageus
which when found permits the large esophagoscope to pass into the
stomach, will be recognized as characteristic by anyone who has seen
the condition. In the cases with but little esophageal distension the
diagnosis is confirmed by the constancy of the obstruction to a barium
mixture at the phrenic level, while at esophagoscopy the usual
resistance at the hiatus esophageus is found not to be increased, and
no other local lesion is found as the esophagoscope enters the
stomach. It is the failure of the diaphragmatic pinchcock to open, as
in the normal deglutitory cycle, rather than a spasmodic tightness,
that obstructs the food. The presence of organic stenosis at the
hiatus may remove the case altogether from the spasmodic class, or a
cicatricial or infiltrated narrowing may be the result of static
esophagitis. A compressive stenosis due to hepatic abnormality may
simulate spasmodic stenosis as shown by Mosher, who believes that 75
per cent of so-called cardiospasms are organic.

Treatment of hiatal esophagismus (so-called cardiospasm) consists in
the over-dilatation of the diaphragmatic pinchcock or hiatus
esophageus, and in proper remedial measures for the removal of the
underlying neurosis. The simple passage of the esophagoscope suffices
to cure some cases. Further dilatation by endoscopic guidance may be
obtained by the introduction of Mosher's divulsor through the
esophagoscope, by which accurate placement is obtained. The distension
should not usually exceed 25 mm. Numerous water and air bags have been
devised for stretching the hiatus, and excellent results have been
obtained by their use. Possibly some of the cures have been due to the
dilatation of organic lesions, or to the crowding back of an enlarged
malposed, or otherwise abnormal left lobe of the liver, which Mosher
has shown to be an etiologic factor.

Certain cases prove very obstinate of cure, and require esophageal
lavage for the esophagitis, and feedings through the stomach tube to
increase nutrition and to dilate the contracted stomach. Gastrostomy
for feeding rarely becomes necessary, for a stomach tube can always be
placed with the esophagoscope if it will not pass otherwise.
Retrograde dilatation with the fingers through a gastrostomy opening
has been done, but seems hardly warranted in view of the excellent
results obtainable from above. Instructions should be given concerning
the proper mastication of food, and during treatment the frequent
partaking of small quantities of liquid foods is recommended. Liquids
and foods should be neither hot nor cold. The neurologist should be
consulted in cases deemed neurotic.

[96a.-Functional hiatal stenosis. Cramp of the diaphragmatic pinchcock
(so-called cardiospasm).]

Endocrine imbalance should be investigated and treated, as urged by
MacNab.

Esophageal antiperistalsis is the name given by the author to a
heretofore undescribed disease associated with regurgitation of food
from the esophagus, the food not having reached the stomach. It may be
continuous or paroxysmal and may be of so serious a degree as to
threaten starvation. The best treatment in severe cases is gastrostomy
to put the esophagus at rest. Milder cases get well under liquid diet,
rest in bed, endocrine therapy, cure of associated abdominal disease,
etcetera.





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