Functional Hiatal Stenosis Hiatal Esophagismus Phrenospasm Diaphragmatic Pinchcock Stenosis

Categories: DISEASES OF THE ESOPHAGUS
Sources: 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 corr borated 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.