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Spasmodic Stenosis Of The Esophagus
Category: DISEASES OF THE ESOPHAGUS
Source: A Manual Of Peroral Endoscopy And Laryngeal Surgery
Etiology - The functional activity of the esophagus is dependent upon
reflex action. The food is propulsed in a peristaltic wave by the same
mechanism as, and through an innervation (Auerbach and Meissner
plexus) similar to that which controls intestinal movements. The vagus
also is directly concerned with the deglutitory act, for swallowing is
impossible if both vagi are cut. Anything which unduly disturbs this
reflex arc may serve as an exciting cause of spasmodic stenosis.
Bolting of food, superficial erosions, local esophageal disease, or a
small foreign body, may produce spasmodic stenosis. Spasm secondary to
disease of the stomach, liver, gall bladder, appendix, or other
abdominal organ is clinically well recognized. A perpetuating cause in
established cases is undoubtedly nerve cell habit, and in many cases
there is an underlying neurotic factor. Shock as an exciting cause has
been well exemplified by the number of cases of phrenospasm developing
in soldiers during the World War.
Cricopharyngeal spasmodic stenosis usually presents the subjective
symptom of difficulty in starting the bolus of food downward. Once
started, the food passes into the stomach unimpeded. Regurgitation, if
it occurs, is immediate. The condition consists in a tonic
contraction, ahead of the bolus, of the circular fibers of the
inferior constrictor known as the cricopharyngeus muscle, or in a
failure of this muscle to relax so as to allow the bolus to pass. In
either case the disorder may be secondary to an organic lesion. Local
malignant disease or foreign bodies may be the cause. Globus
hystericus, lump in the throat, and the sense of constriction and
choking during emotion are due to the same spasmodic condition.
Diagnosis - At esophagoscopy there will be found marked exaggeration
of the usual spasm which occurs at the cricopharyngeus during the
introduction of the tube. The lumen may assume various shapes, or be
so tightly closed that the folds form a mammilliform projection in the
center. If the spasm gradually yields, and a full-sized esophagoscope
passes without further resistance, it may be stated that the esophagus
is of normal calibre, and a diagnosis of spasmodic stenosis can be
made. Considerable experience is required to distinguish between
normal and pathologic spasm in an unanesthetized individual. To the
less experienced esophagoscopist, examination under ether anesthesia
is recommended. Deep anesthesia will relax the normal cricopharyngeal
reflex closure as well as any abnormal spasm, thus assisting in the
differentiation between an organic stricture and one of functional
character. Under deep general anesthesia, however, it is impossible to
differentiate between the normal reflex and a spasmodic condition,
since both are abolished. Many cases of intermittent esophageal
stenosis supposed to be spasmodic are due to organic narrowness of
lumen plus lodgement of food, obstructive in itself and in the
esophagitis resulting from its presence. The organic narrowing,
congenital or pathologic, is readily recognizable esophagoscopically.
Treatment.--The fundamental cause of the disturbance of the reflex
should be searched for, and treated according to its nature. Purely
functional cases are often cured by the passage of a large
esophagoscope. Recurrences may require similar treatment.
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Previous: Diffuse Dilatation Of The Esophagus