esophagus health

Cardiac Incontinence - Cardias Incontinente by G.Bertelli

Generality

Cardiac incontinence is a disorder of the digestive system, characterized by malfunctioning of the cardia, a sort of valve that regulates the passage of food from the esophagus to the stomach, preventing it from turning back.

This problem recognizes several pathological causes. In any case, the cardias can no longer contract sufficiently to avoid the ascent of the acid gastric contents towards the esophagus. Cardiac incontinence is manifested by a characteristic symptomatology, represented by retrosternal burning, persistent cough, regurgitation, chest pain and excessive salivation.

Diagnosis is defined by radiographic studies with barium and esophageal manometry.

Treatment varies according to the extent of cardiac incontinence, but surgery is generally the final solution.

What's this

Cardial incontinence is a pathological condition that affects the cardia .

As a rule, this sort of valve has the task of passing the ingested food from the esophagus to the stomach, preventing it from turning back. In cardial incontinence, this mechanism fails and regurgitation of gastric material occurs. The phenomenon determines pyrosis, that is a sensation of burning with a thoracic location determined by the irritation of the esophageal wall.

What is the cardias?

  • The cardia is a structure belonging to the gastrointestinal system, located in the upper part of the abdomen, between the bottom of the stomach and the end of the esophagus .
  • The cardia has a shape of a ring ; inside, the passage takes place between the mucosa of the esophagus and the mucosa constituting the acid barrier of the stomach. The lumen of the esophagus opens into the cardia via the cardial orifice .
  • The cardia performs the functions of a sphincter, although it does not present the typical characteristics (such as the thickening of the muscle fibers); the containment mechanism to which he is a deputy is assisted by the curve that the esophagus forms at the junction with the stomach (angle of His). In this regard, it should be remembered that a sphincter is generally defined as a muscular ring that surrounds an orifice and regulates the passage of material through it, modifying its diameter.
  • Normally, the cardia is closed and opens only when food is swallowed, preventing the acidic contents of the stomach from entering the esophagus. In practical terms: the cardias expands while we eat, so the food bolus manages to pass into the stomach; once the food arrives in the stomach, however, the sphincter contracts to prevent the gastric juices from escaping into the esophagus.

Curiosity: why is it called "cardias"?

The cardia is so named because - in correspondence with the region in which it is located - the stomach is related to the heart, through the interposition of the diaphragm .

Causes and Risk Factors

The cardial incontinence derives from a malfunction of the cardia, secondary to its anomalous contraction and / or dilation . In practice, after passing the food bolus through the opening of the muscular sphincter between the esophagus and the stomach, the gastric contents are not contained in the seat. This results in the reflux of stomach acids .

The main reason for cardiac incontinence is precisely due to the structure of the sphincter, which exposes it to functional alterations. These include cardiospasm, a pathological condition that prevents the correct transit of food.

Cardias: how does it participate in digestion?

To better understand the causes that can induce cardiac incontinence, it is necessary to remember some notions related to the anatomy of the esophagus and the stomach and their functioning during the ingestion of food .

  • The esophagus is a muscle-membranous duct, about 25-30 centimeters long and 2-3 cm wide, which connects the pharynx to the stomach . This structure is located almost entirely in the chest, in front of the spine.
  • The walls of the esophagus consist of a layer of epithelial lining similar to that of the mouth, while they are surrounded externally by two layers of smooth musculature. The esophageal mucosa is rich in mucus-producing glands, mucus which has the function of lubricating the walls facilitating the passage of swallowed food .
  • By contracting in the act of swallowing, the esophageal muscular component pushes the food downwards, in the direction of the stomach, from which it is separated from the cardia, which prevents ingested foods and gastric juices from rising. In other words, after passing a food morsel, the esophagus contracts to advance it and the contraction wave propagates downwards.
  • As anticipated, the cardias have the task of passing the food ingested by the esophagus to the stomach, preventing it from turning back. The functioning of this structure is ensured by the muscles of the esophagus . Under normal conditions, the latter remain contracts in correspondence with the cardia; for this reason, at rest, they compress the lumen and prevent the contents of the stomach from rising. On the other hand, during swallowing, the muscles of the esophagus relax and allow the bolus to pass. In this way, the esophagus - which is not protected by the gastric barrier like the stomach - does not come into contact with acidic contents of this and is not damaged.
  • The vagus nerve endings have the task of inhibiting the cardia, while the afferents of the sympathetic nervous system deal with the opposite activity, ie they have an exciting function.

Cardiac incontinence: possible causes, aggravating and predisposing factors

The cardias may be partially or completely compromised in its operation.

Cardiac incontinence can be caused by:

  • Generalized loss of intrinsic sphincter tone ;
  • Inappropriate transient releases (ie not related to swallowing, but triggered by gastric distension or pharyngeal stimulation below the threshold values).

The increase in the size of the cardia may be related to the hiatal hernia, that is, the outflow of a part of the wall of the stomach towards the outside, just near the sphincter.

Cardiac incontinence can be caused by inflammatory processes (eg esophagitis, Barret's esophagus etc.) that involve the mucous membrane of the cardia . This condition can also occur as secondary dysfunction to other diseases that can alter the motility and function of the cardia, such as esophageal cancer or the presence of various lesions (cysts, nodules or diverticula).

Other factors that contribute to an altered competence of the cardias are:

  • Abuse of gastrolesive drugs or use of medicines that reduce the pressure of the sphincter (including anticholinergics, antihistamines, tricyclic antidepressants and calcium channel blockers);
  • Overweight / Obesity;
  • Tobacco smoke;
  • Bad eating habits (eg excessive consumption of coffee, alcohol, fatty foods and carbonated drinks);
  • aerophagia;
  • Stress;
  • Pregnancy.

In the absence of other triggering conditions, cardial incontinence can be favored by an abnormal innervation of the esophageal musculature.

Symptoms and Complications

The characteristic symptomatology of cardial incontinence can start at any time in life; in general, the manifestations appear gradually.

The problems that can occur include:

  • Retrosternal acidity and burning (heartburn);
  • Hiccup;
  • Sialorrhea (excessive salivation);
  • Halitosis;
  • Nausea;
  • He retched;
  • Pain in the mouth of the stomach;
  • Difficulty or pain when swallowing food (dysphagia);
  • Frequent eructations.

In cardiac incontinence, dysphagia may be associated with:

  • Acid regurgitation of undigested food, shortly after meals;
  • Cough attacks;
  • Suffocation;
  • Chest pain, which can increase after eating;
  • Stomach ache;
  • Weight loss.

Cardiac incontinence: possible complications

Cardiac incontinence tends to progressively worsen over time and represents one of the possible causes of gastroesophageal reflux disease (GERD) .

Other possible consequences of the prolonged incompetence of the cardias include:

  • Esophagitis;
  • Esophageal peptic ulcers;
  • Esophageal stricture;
  • Perforation of the esophagus;
  • Lung infection due to inhalation of reflux material (pneumonia ab ingestis).

In the most serious cases, the patient suffering from cardiac incontinence can also suffer from hoarseness, pharyngitis, dysphonia (altered tone), laryngitis and bronchitis.

Diagnosis

When the episodes of malaise are repeated frequently, it is advisable to consult your doctor or a gastroenterologist, for a careful evaluation.

The diagnostic procedure to ascertain the presence of cardiac incontinence involves, first of all, the collection of information relating to the patient's clinical history ( anamnesis ) and the physical examination, in association with blood, urine and faeces analyzes .

To complete the assessment of cardiac incontinence, three are the most commonly used surveys:

  • X-ray with barium . A sequence of radiographic images is performed after the patient has ingested a barium-based preparation. In the presence of cardial insufficiency, the peristaltic movement through the esophagus is not normal and is associated with an accelerated or delayed passage of the barium in the stomach.
  • Esophagogastroduodenoscopy (EGDS) . A flexible instrument, called an endoscope, is introduced from the mouth to allow the doctor to directly observe the inside of the esophagus, stomach and duodenum.
  • Esophageal manometry . This survey evaluates esophageal function and, due to its sensitivity, provides diagnostic confirmation. Esophageal manometry allows us to record the characteristics of esophageal peristaltic waves (duration, amplitude and the way in which they propagate), verifying which contractions occur at the level of the cardia during swallowing (ie how it relaxes and contracts and if it does so in an appropriate way). ).

In case of doubt, an ultrasound examination of the abdomen or other imaging studies (CT or MRI) may be required.

Treatment and Remedies

As for treatment, the options are variable and vary based on the extent of cardiac incontinence. Some medications can be used temporarily for mild or moderate cases, but the most lasting relief is determined by surgical therapy.

Drugs used in case of cardiac incontinence

Drug therapy is indicated especially for patients with mild cardiac incontinence. This is based on medicines that protect from gastric acid secretion and keep the symptoms of gastro-esophageal reflux disease associated with cardiac dysfunction under control. Generally, gastroprotective drugs (for example, proton pump inhibitors) are used before fasting, and antacids after meals (such as alginates) are used.

In the management of cardiac incontinence, it should be remembered that medicines work only in the short term: drug therapy is not the definitive solution to the problem.

Lifestyle

Treatment of cardiac incontinence involves a series of lifestyle modifications.

In particular, it is necessary to intervene on bad eating habits and erroneous behaviors that can contribute to exacerbating the symptoms. If the disorder always manifests itself with the same characteristics and is a chronic malaise, it is advisable, first of all, to limit the consumption of carbonated beverages and eat slowly. In the diet, then, acidic foods, irritants or that can aggravate gastroesophageal reflux, including citrus fruits, chocolate, alcohol and caffeine should be avoided. Another important trick is to contain the overweight.

Cardiac incontinence surgery

Total remission of cardiac incontinence is possible with surgical therapy. The purpose of treatment is to restore normal sphincter function .

The intervention for the correction of cardiac incontinence can be performed with minimally invasive techniques, such as endoscopic procedures (ie with a surgery performed through the mouth, without any external incision) or laparoscopic, to reconstruct the natural anti-reflux barrier.

Interventions with external access are limited to a few specific cases.

After treatment

After surgery, your doctor may prescribe some drugs that inhibit gastric acid secretion (proton pump inhibitors).

To reduce symptoms of cardiac incontinence, both before and after treatment, patients can:

  • Chew food well;
  • Eat slowly, maintaining a vertical position;
  • Avoid consuming food immediately before going to sleep;
  • Use different pillows to sleep, so as to keep the head fairly upright and facilitate the emptying of the esophagus by gravity.