Diseases of the esophagus in children. teaching aid. Reflux in young children: causes, symptoms and treatment features

Gastroesophageal (gastroesophageal) reflux refers to the return of food eaten and stomach acid back into the esophagus. Due to the unformed digestive system in infants, this phenomenon occurs constantly and does not pose a danger to the health of the baby. The state reaches its peak at the age of 4 months, gradually fading away by the 6-7th month from birth and completely disappearing by 1-1.5 years.

In a newborn child, the esophagus is anatomically short, and the valve that blocks the passage of food back from the stomach is poorly developed. This results in frequent regurgitation of milk or adapted formula, depending on the type of feeding.

According to the predominant contents thrown into the esophagus, refluxes are distinguished:

1. Alkaline, in which substances are thrown from the stomach and intestines with an admixture of bile and lysolecithin, the acidity in this case exceeds 7%.
2. Acidic - contributes to the entry of hydrochloric acid into the esophagus, lowering its acidity to 4%.
3. Low acid - leads to acidity from 4 to 7%.

Symptoms of gastroesophageal reflux

In addition to heartburn and regurgitation, reflux in a child is often disguised as symptoms of diseases of other organs and systems:

1. Digestive disorders: vomiting, pain in the upper part of the stomach, constipation.
2. Inflammation of the respiratory system. The reflux of gastric contents is sometimes not limited to the esophagus and passes further into the pharynx, getting from there into the respiratory tract. It causes:

• Cough, mainly at night, sore throat, hoarse crying in infants.
• Otitis (inflammation of the ear).
• Chronic pneumonia, non-infectious bronchial asthma.

1. Diseases of the teeth. This is caused by the fact that acidic gastric juice corrodes tooth enamel, leading to the rapid development of caries and tooth decay.
2. Cardiovascular disorders: arrhythmia, chest pain in the region of the heart.

Treatment of gastroesophageal reflux

An uncomplicated type of condition does not need medication, it is enough to adjust the diet and feeding habits of the child.

1. Feed your baby more often, but in smaller portions.
2. In case of allergies, exclude cow's milk proteins from the diet of newborns and nursing mothers. Use for feeding special mixtures that do not contain milk proteins, such as Frisopep, Nutrilon Pepti. The effect is more often achieved after three weeks of following this diet.
3. Add thickeners to the diet or use ready-made anti-reflux mixtures. They contain substances that inhibit the reverse flow of food into the esophagus. This type of food includes locust bean gum or starch (potato, corn). Mixtures where gum acts as a thickener - Nutrilak, Humana Antireflux, Frisovoy, Nutrilon; starch thickener is present in baby food brands NAN and Samper Lemolak. If the baby is breastfed, a thickener is added to the expressed milk, which can be bought at a pharmacy. Children older than 2 months are allowed to give a teaspoon of rice porridge without milk before feeding, which helps to thicken the food eaten.
4. After feeding, ensure the baby stays upright for at least 20 minutes. For infants, wearing a column immediately after eating is suitable.

In the absence of the effect of such measures, the use of drugs will be required.

• Antacids (Maalox, Phosphalugel), enzymes (Protonix) are used to neutralize gastric acid and reduce its harm to the esophageal mucosa.
• To speed up digestion and strengthen the esophageal sphincter, drugs Raglan, Propulsid have been developed.
• The elimination of manifestations of heartburn in an infant is facilitated by the intake of alginates.
• A decrease in the production of stomach acid is caused by proton pump inhibitors (omeprazole).
• Histamine H-2 blockers (Pepsid, Zantak).

If such treatment has not brought noticeable improvements and the condition is aggravated by the presence of diverticula or hernias of the esophagus, there will be a need for surgical intervention. This operation is called a fundoplication and consists in the formation of a new gastroesophageal sphincter. The esophagus is lengthened and connected to the entrance to the stomach by a special muscular ring. The procedure allows you to nullify attacks of pathological reflux.

The following diagnostic methods will help determine the feasibility of a surgical operation:

• A barium x-ray allows you to analyze the work of the upper part of the digestive system.
• 24-hour pH monitoring involves placing a thin tube into the esophagus to test for acidity and the severity of regurgitation.
• Endoscopy of the esophagus and stomach allows you to determine the presence of ulcers, erosion, swelling of the mucous membrane of organs.

• Sphincteromanometry provides data on the functioning of the organ that connects the esophagus to the stomach. The degree of sphincter closure after a meal is studied, which is directly related to episodes of reflux.
• An isotope study allows you to determine the movement of food through the upper part of the digestive system in a child.

If complicated gastroesophageal reflux begins to progress, there is a risk of complications in the form of gastroesophageal reflux disease. There are also more serious, and even life-threatening consequences of this disease, such as:

• inability to eat due to pain and discomfort, which will lead to weight loss and beriberi;
• erosive damage to the esophagus, its pathological narrowing, esophagitis (inflammation);
• food entering the respiratory tract, which can cause suffocation;
• bleeding and perforation of the organ;
• degeneration of the cells of the esophageal mucosa, which creates prerequisites for oncological diseases.

In most cases, gastroesophageal reflux in a child under one year old does not cause concern to doctors, and there is no need to treat it, since it disappears without a trace with age. If the condition continues to recur in children older than one and a half years, even with a decrease in the number of episodes, it is advisable to consult a doctor with a subsequent examination.

Esophagitis in a child is a disease of the gastrointestinal tract, characterized by inflammation of the esophageal mucosa. With a severe degree of development, deeper tissues of the esophagus undergo changes.

Esophagitis is a fairly common occurrence in gastroenterology. It can develop on its own or occur against the background of other diseases.

The disease can be acute and chronic. The chronic form is characterized by mild symptoms. The disease develops gradually against the background of other pathologies. The acute form proceeds with pronounced symptoms and is the result of a direct effect on the mucous tissue of the esophagus.

The most common forms of esophagitis in children are catarrhal and edematous. A pathological condition can occur as a result of thermal, chemical, exposure to the mucous membrane - a burn of the esophagus.

Acute esophagitis also differs in the degree of tissue damage. From superficial to deep lesions of submucosal tissues, accompanied by bleeding. In the chronic form, stenosis may develop, namely the narrowing of the lumen of the esophagus.

The reasons

Esophagitis (inflammation of the mucous tissues of the esophagus) in children is a fairly common occurrence. The causes of the acute form of inflammation are in most cases damaging in nature of a short-term effect. Factors that cause damage to the mucous membrane are:

• acute viral diseases caused by infections (flu, diphtheria, scarlet fever and others);
• mechanical injury;
• thermal and chemical burns;
• food allergy.

Chronic esophagitis develops for reasons such as:

• constant consumption of too hot, spicy food,
• disruption of the stomach,
• allergy,
• hypovitaminosis,
• prolonged intoxication of the body.

Medicine distinguishes reflux esophagitis as a separate disease, which occurs against the background of malfunctioning of the lower esophageal sphincter and shortening of the esophagus.

Symptoms

Signs of acute esophagitis in a child are expressed depending on the stage of inflammation. The child feels pain during swallowing, discomfort from eating hot or cold food.

In severe forms of development, esophagitis is manifested by obvious symptoms, including:

• intense chest pain
• pain during swallowing
• heartburn,
• increased salivation.

After some time, the symptoms may fade away, but after a couple of weeks, scars form on the walls of the esophagus, which is the cause of stenosis.

The following signs may indicate the development of a chronic form of esophagitis in a child:

• frequent heartburn, aggravated after eating fatty and spicy foods, soda;
• belching;
• heavy breathing during sleep.

Chronic inflammation of the esophageal mucosa is characterized by frequent pneumonia, the development of bronchial asthma.

In children under one year old, esophagitis is manifested by frequent regurgitation immediately after feeding. Against this background, in some cases there is a risk of developing symptoms of malnutrition - emaciation with a lack of body weight in relation to length.

Diagnosis of esophagitis

Since the clinical manifestations of inflammation of the esophageal mucosa are pronounced, it is not difficult to diagnose the disease. Localization of pain symptoms is characteristic and specific. Questioning the patient allows you to easily establish the cause of the development of the inflammatory process.

To diagnose the disease, a gastroenterologist uses an endoscope. But esophagoscopy is performed no earlier than 6 days after the onset of symptoms. During an endoscopic examination, a biopsy of the mucosa is taken for histological analysis.

An X-ray is also additionally performed, which allows to detect changes in the contours of the esophagus, ulcers, and edema of the walls of the esophagus.

Complications

What is the danger of esophagitis in a child? Timely and adequate treatment will avoid the development of complications. If the inflammation of the mucosa is not treated, the risk of getting consequences such as:

• an ulcer accompanied by a shortening of the esophagus;
• stenosis;
• perforation of the walls of the esophagus;
• abscess;
• Barrett's disease is a persistent replacement of mucous tissues.

Esophagitis of severe form can cause the formation of malignant tumors.

Treatment

What can you do?

Depending on the severity, form of the disease, treatment is prescribed.

The first aid for acute esophagitis caused by a chemical burn is gastric lavage.

With a mild form of acute inflammation, it is necessary to limit the child's food intake for 1-2 days.

Tactics for the treatment of a mild form of the disease:

• sparing diet number 1,
• taking antacids and astringents,
• taking funds that regulate the motility of the upper gastrointestinal tract.

The last meal should be 2-3 hours before going to bed. During treatment, it is recommended to limit the child in the consumption of hot, rough and spicy foods, foods that contribute to the production of gastric juice.

What does a doctor do?

In severe esophagitis with pronounced intoxication, it is recommended:

• careful nutrition,
• taking enveloping and antacid drugs,
• droppers with detoxification solutions,
• taking antibiotics.

Ulcerative esophagitis requires mandatory antibiotic therapy. Washing in this case is contraindicated. If medical treatment is not effective enough, surgical debridement is performed.

In the absence of complications, the prognosis of treatment is favorable.

Prevention

To prevent the development of acute esophagitis in a child caused by a thermal burn, you need to carefully monitor the temperature of the food and drinks that the baby consumes. It is also necessary to limit the child from eating spicy and rough foods, which can damage the mucosa of the esophagus.

Very often, young children are taken to the hospital with a chemical burn of the esophagus. To protect the baby from an accident, it is necessary to store household chemicals in a place inaccessible to him.

To prevent the development of complications in chronic esophagitis, you should undergo regular examination by a gastroenterologist. If necessary, undergo treatment. Children suffering from a chronic form of esophagitis are recommended a sparing diet, as well as spa treatment.

In the article you will read everything about the methods of treating a disease such as esophagitis in children. Specify what effective first aid should be. How to treat: choose drugs or folk methods?

You will also learn how untimely treatment of esophagitis in children can be dangerous, and why it is so important to avoid the consequences. All about how to prevent esophagitis in children and prevent complications.

And caring parents will find on the pages of the service full information about the symptoms of esophagitis in children. How do the signs of the disease in children at 1.2 and 3 years old differ from the manifestations of the disease in children at 4, 5, 6 and 7 years old? What is the best way to treat esophagitis in children?

Take care of the health of your loved ones and be in good shape!

Gastroesophageal reflux disease (GERD) in children- a chronic relapsing disease that occurs when retrograde throwing of the contents of the stomach and the initial sections of the small intestine into the lumen of the esophagus. Main esophageal symptoms: heartburn, belching, dysphagia, odynophagia. Extraesophageal manifestations: obstruction of the bronchial tree, disorders of the heart, dysfunction of the upper respiratory tract, erosion of tooth enamel. For diagnosis, intraesophageal pH-metry, endoscopy and other methods are used. Treatment depends on the severity of GERD and the child's age, and includes dietary and lifestyle changes, antacids, PPIs, and prokinetics, or fundoplication.

Esophageal stenosis is a narrowing of the lumen of the organ resulting from the process of scarring of ulcerative defects of the mucous membrane. At the same time, against the background of chronic inflammation and involvement of the periesophageal tissues, periesophagitis develops. Posthemorrhagic anemia is a clinical and laboratory symptom complex that appears as a result of prolonged bleeding from esophageal erosions or pinching of intestinal loops in the esophageal opening of the diaphragm. Anemia in GERD is normochromic, normocytic, normoregenerative, the level of serum iron is somewhat reduced. Barrett's esophagus is a precancerous condition in which the squamous stratified epithelium characteristic of the esophagus is replaced by a columnar epithelium. Detected in 6% to 14% of patients. Almost always degenerates into adenocarcinoma or squamous cell carcinoma of the esophagus.

Diagnosis of GERD in children

Diagnosis of gastroesophageal reflux disease in children is based on the study of anamnesis, clinical and laboratory data and the results of instrumental studies. From the anamnesis, the pediatrician manages to establish the presence of dysphagia, the wet spot symptom, and other typical manifestations. Physical examination is usually uninformative. In the KLA, a decrease in the level of erythrocytes and hemoglobin (with posthemorrhagic anemia) or neutrophilic leukocytosis and a shift of the leukocyte formula to the left (with bronchial asthma) can be detected.

Intraesophageal pH-metry is considered the gold standard in the diagnosis of GERD. The technique makes it possible to directly identify GER, assess the degree of damage to the mucous membrane and clarify the causes of the pathology. Another mandatory diagnostic procedure is EGDS, the results of which determine the presence of esophagitis, the severity of esophagitis (I-IV) and esophageal motility disorders (A-C). X-ray examination with contrasting makes it possible to confirm the fact of gastroesophageal reflux and to detect a provoking pathology of the gastrointestinal tract. If Barrett's esophagus is suspected, a biopsy is indicated to detect epithelial metaplasia. In some cases, ultrasound, manometry, scintigraphy and esophageal impedancemetry are used.

Treatment of GERD in children

There are three directions of treatment of gastroesophageal reflux disease in children: non-drug therapy, pharmacotherapy and surgical correction of the cardiac sphincter. The tactics of a pediatric gastroenterologist depends on the age of the child and the severity of the disease. In young children, therapy is based on a non-pharmacological approach, including postural therapy and nutritional correction. The essence of treatment with the position is to feed at an angle of 50-60 O, maintaining an elevated position of the head and upper torso during sleep. The diet involves the use of mixtures with antireflux properties (Nutrilon AR, Nutrilak AR, Humana AR). The feasibility of drug treatment is determined individually, depending on the severity of GERD and the general condition of the child.

The treatment plan for GERD in older children is based on the severity of the disease and the presence of complications. Non-drug therapy consists in the normalization of nutrition and lifestyle: sleep with a head end raised by 14-20 cm, weight loss measures for obesity, exclusion of factors that increase intra-abdominal pressure, a decrease in the amount of food consumed, a decrease in fats and an increase in proteins in the diet, refusal use of provocative medications.

The list of pharmacotherapeutic agents used for GERD in pediatrics includes proton pump inhibitors - PPIs (rabeprazole), prokinetics (domperidone), motility normalizers (trimebutine), antacids. Combinations of medications and prescribed regimens are determined by the form and severity of GERD. Surgical intervention is indicated for pronounced GER, ineffectiveness of conservative therapy, the development of complications, a combination of GERD and hiatal hernia. Usually, a Nissen fundoplication is performed, less often - according to Dor. With the appropriate equipment, laparoscopic fundoplication is resorted to.

Forecast and prevention of GERD in children

The prognosis for gastroesophageal reflux disease in most children is favorable. When Barrett's esophagus is formed, there is a high risk of malignancy. As a rule, the development of malignant neoplasms in pediatrics is extremely rare, however, in more than 30% of patients in the next 50 years of life, adenocarcinoma or squamous cell carcinoma occurs in the affected areas of the esophagus. Prevention of GERD involves the elimination of all risk factors. The main preventive measures are rational nutrition, exclusion of the causes of a prolonged increase in intra-abdominal pressure and limiting the intake of provoking medications.

Ministry of Health and Social Development of the Russian Federation

Department of Pediatrics

Teaching aid

for students of pediatric faculties, interns, residents and pediatricians.

Diseases of the esophagus in children

Development of the esophagus in utero

The development of the esophagus begins from the 4th week of embryogenesis from the caudal foregut. At the same time, the laying of the larynx, trachea and bronchial tree occurs, by dividing the primary (pharyngeal) intestine into the respiratory and digestive tubes, the violation of which leads to the occurrence of tracheoesophageal fistulas, atresia, tubular stenosis and diverticula of the esophagus.

Initially, the esophagus looks like a tube, the lumen of which is filled due to the active proliferation of the cell mass. The process of recanalization - the formation of the lumen of the esophagus - occurs in the III-IV month. Violation of this process causes the development of such congenital malformations of the esophagus as stenosis, stricture, membranes, narrowing of the esophagus.

From the 11th week, the border between the esophagus and stomach becomes visible.

The innervation of the esophagus is formed from the 4th week from the vagus nerves and from the anlages of the sympathetic trunks. Intramural ganglia are formed on the 5th month of fetal development. Violation of the development of the nerve plexuses of the cardiac esophagus leads to the development of congenital chalazia, achalasia of the cardia.

Later than the 4th month, the distal end of the esophagus slowly descends into the abdominal cavity. Violation of this process can lead to the development of a hernia of the esophageal opening of the diaphragm and short esophagus.

Normal anatomy and physiology of the pediatric esophagus

By birth, the esophagus is mostly formed. The entrance to the esophagus in a newborn is located at the level of the disc between the III and IV cervical vertebrae and constantly decreases with age: by the age of 2 it is at the level of the IV-V vertebrae, and at 12 years old it is at the level of the VI-VII vertebrae as in an adult.

The location of the esophagus in relation to neighboring organs in a newborn does not differ from that of an adult. The esophagus in the sagittal plane follows the curves of the spine. If we consider the position of the esophagus from the front (frontally), then in its course from the neck to the stomach it has an S-shaped bend.

The lower limit of the esophagus, which opens into the stomach, remains constantly at level X – XI thoracic vertebrae.

There are 3 physiological narrowings: upper (pharyngeal), middle (aortobronchial) and lower (diaphragmatic), which correspond to 2 expansions of the esophagus. Physiological narrowing of the esophagus (diameter reduction by more than 1/3) in newborns and children of the first year of life is relatively weakly expressed, lower narrowing is better expressed. In the future, they are formed.

The lumen of the esophagus in the cervical and abdominal parts is usually closed, and in the thoracic region it contains a small amount of air. The dynamics of the diameter of the lumen of the esophagus in the age aspect is presented in Table 1.

Table 1. The diameter of the lumen of the esophagus in children depending on age.

The dynamics of the distance from the dental arches to the inlet of the stomach, depending on age, is presented in Table. 2.

Table 2. Age dynamics of the length of the esophagus in children.

In newborns, the walls of the esophagus are thinner than in older children. The epithelium of the mucous membrane thickens rapidly after birth.

The muscular layer of the esophagus in newborns is less developed than in adults, the circular, especially the inner circular layer of muscles in the lower esophagus, is better expressed. The mucous and submucosal membranes of the esophagus are fully formed by the time of birth. The submucosal layer in children is rich in blood vessels and lymphoid elements.

The innervation of the esophagus is complex and peculiar. Parasympathetic innervation of the esophagus is carried out through the vagus and recurrent nerves, sympathetic - through the nodes of the border and aortic plexuses, branches of the pulmonary and cardiac plexuses, fibers of the solar plexus and ganglia of the subcardia.

The intramural nervous apparatus consists of 3 plexuses closely related to each other - adventitial, intermuscular and submucosal. They revealed peculiar ganglion cells (Dogel cells), which largely provide autonomous internal innervation and local regulation of the motor function of the esophagus. The innervation of the legs of the diaphragm, especially the right one, is provided by branches of the phrenic nerves.

Of particular interest in children are the anatomical and physiological features of the abdominal part of the esophagus, which includes part of it from the esophageal opening of the diaphragm to the transition to the stomach. On the border between the esophagus and the stomach is the cardia, which unites the place where the esophagus flows into the stomach and the esophageal end of the stomach. In the region of the cardia, there is a transition of the mucous membrane of the esophagus into the mucous membrane of the stomach.

The function of the abdominal esophagus is to prevent retrograde reflux of gastric contents into the lumen of the esophagus. This function is performed by valve and sphincter mechanisms.

The valve mechanism includes the Gubarev valve, formed by a fold of the mucous membrane (plica cardiaca), protruding into the cavity of the esophagus and the loop of Willis, which is a group of muscle fibers of the internal oblique muscle layer of the stomach. In addition, the magnitude of the His angle is important (the sharper it is, the more powerful the mechanism) formed by the wall of the abdominal part of the esophagus and the adjacent wall of the fundus of the stomach. The sphincter mechanism is represented by the legs of the diaphragm, the freno-esophageal membrane (fascia) of Laimer, as well as a zone of increased pressure in the distal esophagus for 1.5-2 cm above and below the diaphragm.

In newborns, the thickness of the cardiac sphincter is 0.8-0.9 mm, and its length is 4-5 mm. By the end of the first year of life, the dimensions increase, respectively, to 1.5 mm and 5-8 mm. Thus, the length of the zone of increased intraluminal pressure at the level of the lower end of the esophagus changes, which contributes to the enhancement of its sphincter function.

In infants, the cardiac sphincter is located under the diaphragm or at its level. In the future, the cardiac thickening of the muscular membrane moves away from the diaphragm in the distal direction.

Weak development of the muscular membrane of the esophagus and the cardia of the stomach in children of the first years of life contributes to the insufficient severity of the His angle. It is believed that the critical value of the His angle for the appearance of insufficiency of the obturator function of the cardia is 90 °.

There is also insufficient development of the circular layer of the muscular membrane of the cardial part of the stomach. As a result, Gubarev's valve is almost not expressed. The same applies to the loop of Willis, which does not completely cover the cardia of the stomach. As a result, the cardiac sphincter of the stomach in children is functionally defective, which can contribute to the reflux of stomach contents into the esophagus. The lack of tight coverage of the esophagus by the legs of the diaphragm, impaired innervation with increased intragastric pressure contribute to the ease of regurgitation and vomiting.

Classification of diseases of the esophagus in children

It is traditionally accepted to divide diseases of the esophagus into congenital (anomalies and malformations) and acquired, among which a special place is given to inflammatory diseases and functional disorders.

There are several opinions in the literature about classification of anomalies and malformations of the esophagus. According to one of them, 9 variants of esophageal anomalies are distinguished: 1) complete absence (complete atresia, aplasia); 2) atresia; 3) congenital stenoses; 4) tracheoesophageal fistulas; 5) congenital short esophagus; 6) congenital diverticula; 7) congenital (idiopathic) expansion of the esophagus; 8) duplication of the esophagus; 9) congenital cysts and aberrant tissues in the esophagus. According to other authors, this division seems to be imperfect, since it does not mention the internal short esophagus and abnormal cardiofundal formation. In addition, the division of the 9th variant into two independent types is valid due to the small similarity of their pathogenetic mechanism.

To functional disorders of the esophagus in children, include spasm and insufficiency of the cardia, as well as gastroesophageal prolapse. At the same time, cardiospasm should not be identified with achalasia of the cardia (organic pathology), but its insufficiency with hiatal hernia.

Inflammatory diseases of the esophagus (esophagitis) in children do not have a single classification. The clinic uses a combination of several classifications of esophagitis:

by etiology(septic and aseptic, specific and non-specific, mechanical, physical, drug, allergic, chemical, radiation, infectious, reflux esophagitis, etc.);

along the path of penetration of the etiological factor(endogenous, exogenous, hematogenous, oral, according to the continuation, etc.);

by duration of manifestation(acute, subacute, chronic);

according to clinical and morphological manifestations(catarrhal, erosive, hemorrhagic, fibrinous (pseudomembranous), membranous, necrotic, purulent, ulcerative).

H. Basset (1980) proposed to distinguish 4 stages of esophagitis endoscopically:

Edema and arterial hyperemia of the mucous membrane, an abundance of mucus;

The appearance of single erosions on the tops of the edematous folds of the mucous membrane;

Significant edema and hyperemia with foci of eroded and bleeding mucous membranes;

The "weeping" mucous membrane is diffusely eroded, bleeding at the slightest touch of the endoscope.

main symptoms,

characteristic of diseases of the esophagus in children.

Dysphagia- a disorder in the act of swallowing and difficulty in passing the food bolus through the esophagus, characterized by pain or an unpleasant sensation when swallowing. With functional disorders, solid food is often swallowed easier than liquid food. With organic dysphagia, the disturbances are permanent and continuously intensify.

Regurgitation or regurgitation- involuntary intake of food masses from the esophagus or stomach into the oral cavity. It is a sign of failure of the gastroesophageal valve mechanism or achalasia of the cardia, prolapse of the gastric mucosa into the lumen of the esophagus, but may be an early symptom of congenital anomalies of the esophagus, as well as its acquired lesions. Esophageal regurgitation differs from gastric regurgitation in that the food bolus does not taste sour.

"Wet Pillow Symptom"- nocturnal regurgitation, characteristic of a significant expansion of the esophagus.

Rumination(“chewing gum”) - observed more often in infants, characterized by the repeated return of swallowed food to the mouth through the combined contraction of the stomach. When food enters the mouth, the child holds it and, making several chewing movements, swallows it again.

Belching- sudden involuntary ejection through the mouth of gases from the stomach or esophagus. The mechanism consists in tension and anti-peristaltic movements of the esophagus and stomach with open cardia. In infancy, belching is often associated with aerophagia.

Heartburn- a feeling of warmth, burning behind the sternum, more often in adults in its lower third or epigastric region, sometimes extending to the pharynx, children often point to the oropharyngeal region. It occurs as a result of the reflux of gastric contents into the esophagus, which is due to a combination of insufficiency of the cardiac sphincter, acid-peptic activity of gastric contents and inflammatory changes in the mucosa of the esophagus.

Vomit- a complex neuro-reflex act, in which an eruption occurs more often than gastric (intestinal) contents through the mouth outward. With a significant degree of narrowing of the esophagus, vomiting develops without preceding nausea a few minutes after eating. The vomit does not contain impurities. With diverticula of the esophagus, vomit consists of long-eaten food, they are distinguished by a putrid odor. With burns and ulcers of the esophagus, vomit may contain blood.

Boyt symptom- characterized by rumbling heard when pressing on the side of the neck, which is typical for diverticulitis of the laryngopharynx and upper esophagus.

Mechterstern's symptom- with functional changes in the body, there is a violation of swallowing liquid food to a greater extent than solid food.

Meltzer symptom- when swallowing food, the patient observes the disappearance of the sound of swallowing, usually heard in the region of the heart.

Features of diseases of the esophagus in children

Anomalies and malformations of the esophagus

Esophageal atresia- the absence of the lumen of the esophagus in a certain area, where it usually appears as a fibrous or fibromuscular cord. The incidence of esophageal atresia according to various authors ranges from 1:2000 to 1:5000 newborns. There is an isolated form of esophageal atresia and combined with tracheoesophageal fistula, and the latter is observed 9-10 times more often than "pure" atresia. Usually there are 6 types of congenital obstruction of the esophagus:

1) complete atresia (aplasia);

2) partial atresia;

3) atresia with tracheoesophageal fistula of the proximal segment;

4) atresia with a fistula of the distal segment;

5) atresia with two isolated segment fistulas;

6) atresia with a common fistulous tract.

However, a number of authors distinguish a variant of atresia, in which the oral segment ends blindly, and the distal part of the esophagus is presented in the form of a cord. Other authors talk about 5 types of atresia, combining the 1st and 2nd types into one - esophageal atresia without fistula, and, describing the 6th variant, they talk about tracheoesophageal fistula without atresia.

The frequency of variants of esophageal atresia is different. So, atresia without a fistula is observed in 7.7% of cases; atresia with tracheoesophageal fistula of the proximal segment - in 0.8%; atresia with a fistula of the distal segment is observed in 86.5% of children with this defect; atresia with two isolated fistulas of the segments - in 0.7% of cases; atresia with a common fistulous tract is detected in 4.2%.

With endoscopic examination, it is possible to establish the type of atresia, the length of the proximal segment, to identify its connection with the trachea or bronchi. The blind end of the esophagus is visualized in the form of a bag, devoid of folds, lined with a very light mucous membrane. At the bottom of this bag, an accumulation of mucus is found. In the presence of an esophageal-tracheal fistula, its opening is determined, which is located, most often on the anterolateral wall or near the blind end. However, with a small diameter of the fistula opening or with a pronounced accumulation of mucus, it is not possible to visualize this opening, but it can be suspected by air bubbles entering through the mucus. In this case, esophagoscopy is combined with bronchoscopy and a color test. If a fistula of the distal segment is suspected, intraoperative esophagoscopy is performed through a gastrostomy. To determine diastasis - the distance between the blind ends of the proximal and distal segments - a combined esophagoscopy through the mouth and gastrostomy is performed under X-ray control.

Congenital esophageal stenosis is a consequence of a number of violations of embryogenesis. These include:

violation of the process of recanalization of the embryonic primary intestinal tube, which results in the narrowing of all layers of the wall, hypertrophy of the muscle layer, and the formation of mucous membranes;

excessive growth of tracheal hyaline rings dystopian into the wall of the upper third of the esophagus;

atypical growth in the esophagus of the mucous membrane with a structure characteristic of the stomach (aberrant type);

compression from the outside by abnormally located large vessels (arterial ring or "vascular slingshot" of the esophagus). The following vascular malformations are distinguished: double aortic arch; dextroposition of the aorta; anomalies a. subclavia sin. and a. carotis; anomalies a. subclavia dex.

Congenital stenosis of the esophagus occurs with a frequency of 1:20,000-1:30,000 births and accounts for almost 10% of the total number of esophageal stenoses.

The endoscopic picture in esophageal stenosis is diverse and depends on its shape.

With tubular stenosis, which can be attributed to failed esophageal atresia, a circulatory funnel-shaped narrowing is visualized, often round in shape, located centrally, less often eccentrically. The esophagus above the narrowing is expanded, its mucous membrane, as well as in the area of ​​the narrowing, is little changed or, as a rule, not changed at all. With a slight degree of narrowing, it is passable with a thin endoscope.

The membranes of the esophagus are visualized as if the endoscope was inserted into a blind bag with, as a rule, an eccentrically located round or oblong hole with smooth edges. The membrane itself is usually thin, its integrity can be easily broken during manipulation. The color of the membrane does not differ from the surrounding mucous membrane of the esophagus.

Rinaldo (1974) indicates the typical localization of the membranes of the esophagus: 1) upper (proximal); 2) medium; 3) lower, or distal; 4) in the lower esophageal ring. The difference of the latter lies in the fact that they are lined with rich red epithelium, corresponding to the color of the border of the transition of the mucosa of the esophagus to the gastric mucosa.

Circular stenoses are defined as a narrow, centrally (very rarely eccentrically) located rounded foramen, to which longitudinal folds converge. The mucous membrane in the area of ​​narrowing is not changed, not soldered to the underlying tissues. Above the narrowing, the lumen of the esophagus is expanded, there are no inflammatory changes.

With stenosis caused by a vascular anomaly, transmission pulsation of the esophageal wall at the level of narrowing can be detected. At the same time, unlike other types of congenital stenoses, the esophagoscope tube can be passed through a narrowed area.

An aberrant type of narrowing of the esophagus, caused by ectopia of the gastric mucosa into the esophagus, can occur with a severe erosive and ulcerative lesion.

Doubling the esophagus- duplication of the esophageal wall with the formation of an additional lumen in it, accounts for 19% of all doublings of the gastrointestinal tract. A doubling of the esophagus develops due to a violation of the recanalization of the lumen of the esophagus at the III-IV month of intrauterine development. Doublings of the esophagus are located in the posterior mediastinum, more often on the right, but they can also be located laterally or in pulmonary fissures and simulate a pulmonary cyst. There are spherical (cystic), tubular and diverticular doublings, which have a lumen isolated or communicated with the esophagus. The walls of such doubling consist of one or more muscle layers and have a single course of common muscle fibers and vessels, which distinguishes them from solitary congenital cysts of the esophagus. From the inside, it is lined with a flat secret-producing esophageal epithelium or a cylindrical epithelium of the stomach. Diverticular doublings differ from diverticula mainly in the large size of cavities and fistulas, as well as in their peculiar shape in the form of a “lowered branch” or “spare pocket”. Occasionally, duplications can communicate with the trachea, becoming, in fact, a type of congenital tracheoesophageal fistula.

congenital short esophagus(congenital hiatal hernia), is considered a separate nosological unit. This disease is characterized by the location of the cardial esophagus above the esophageal opening of the diaphragm and the displacement of the stomach into it (the so-called "thoracic" stomach, glabrous stomach), and sometimes other abdominal organs, by an intestinal loop. The cause of this pathology is congenital disorders of the morphoembryonic relationships between the development of the esophagus and stomach.

Endoscopic examination in the distal esophagus shows a picture of esophagitis, often with erosive and ulcerative lesions, fibrinous and necrotic overlays. The mucous membrane of the distal esophagus is bright red in color, with excessive folding, which indicates its gastric origin. There is no cardioesophageal transition, the study shows a constant leakage of gastric contents into the lumen of the esophagus. The intensity of the lesion increases in the distal direction, reaching a maximum at the border of the mucous membranes of the esophagus and stomach, sometimes in the form of cicatricial stenosis. Above the stenosis, suprastenotic expansion of the lumen of the esophagus is determined. With a high degree of stenosis, visible areas of narrowing are light scar tissue without a vascular pattern, on which ulcerative defects may be located.

Congenital (idiopathic) enlargement of the esophagus(synonyms: congenital achalasia of the cardia, cardiospasm, megaesophagus, inorganic stenosis of the esophagus, dystonia of the esophagus) consists in persistent spasm of the cardiac esophagus due to the absence of reflex opening of the cardia during the act of swallowing. Such a disorder occurs as a result of the congenital absence of intramural nerve ganglia in the Auerbach and Meissner plexus of the distal part and cardia of the esophagus, which leads to a change in the smooth muscle fibers and the associated dysmotility of the esophagus and the opening of the cardia.

Currently, there are more than 25 clinical classifications of achalasia cardia. According to D.I. Tamalevichyute and A.M. Vitenas, the most accurate is the clinical and anatomical classification proposed by B.V. Petrovsky (1962), distinguishing 4 stages of achalasia of the cardia:

Early - functional temporary spasm of the cardia without expansion of the esophagus;

Stage of stable expansion of the esophagus and increased motility of the walls;

The stage of cicatricial changes in the cardia (stenosis) with a pronounced permanent expansion of the esophagus and functional disorders (tonus and peristalsis);

The stage of complications with organic lesions of the distal esophagus, esophagitis and periesophagitis.

At endoscopy, an enlarged esophagus with a large amount of contents is visible, which expands well with air insufflation. The cardia is closed, does not open, however, the esophagoscope easily passes through it into the stomach.

Congenital diverticula of the esophagus- saccular protrusions of the esophagus wall, formed by its layers.

There are true diverticula, which preserve the structure of the organ, and false ones, devoid of the muscular membrane. True esophageal diverticula are usually congenital and are similar to cystic duplication of the esophagus. Of the distinguished topographic variants of esophageal diverticula (Zenker's pharyngoesophageal diverticula, bifurcation, epiphrenal and abdominal diverticula), congenital, according to I.L. Tager and M.A. Filippkin (1974), are pharyngeal (pharyngoesophageal) diverticula.

A variant of a false diverticulum of the esophagus is distinguished, the development of which is due to congenital inferiority of the connective tissue elements and the muscular apparatus of the esophageal wall. In this case, during the act of swallowing, the prolapse of the wall develops first, and then the formation of the esophageal diverticulum (pulsion diverticulum). This kind of diverticulum of the esophagus is called temporary (functional, phase), as it appears only during the act of swallowing or in the presence of esophageal dyskinesia. In the literature, there are indications of the possibility of such diverticula changing over time into permanent pulsion (organic) diverticula.

Congenital true diverticula of the esophagus occur in children much more often than acquired, their frequency is 1:2500 newborns. However, according to A.P. Biezin (1964), they are more common, but not diagnosed.

Congenital cysts of the esophagus- this is a malformation (disembryogenesis) of "dormant" or "stray" cells, the remains of a longitudinal septum that laces the respiratory tube from the intestinal one. Cysts may be lined by respiratory (bronchogenic) or gastrointestinal (enterogenic) epithelium.

We managed to find in the literature references to the so-called duplication cysts of the esophagus. The epithelium lining such cysts may originate from any part of the intestine. The cavity of the cyst does not communicate with the lumen of the esophagus. The presence of such a cyst can be suspected by signs of compression of the esophagus from the outside. In some cases, when the cyst cavity is lined with the gastric mucosa, it can ulcerate and drain into the lumen of the esophagus, which, according to some authors, translates it into the category of pseudodiverticula.

Gastroesophageal reflux (GER) is the reverse movement of gastric contents through the esophageal valve back into the esophagus. The thesis "reflux" in Latin means a reverse flow in comparison with natural movement. Gastroesophageal is literally translated from English as gastroesophageal reflux. GER can be a normal physiological or pathological indicator.

Gastroesophageal reflux is normal for children in the first year of life, due to the continued formation of the digestive system. In the process of regurgitation, trapped air and excess food are removed from the gastrointestinal tract, which do not saturate the body with nutrients. Excess food provokes the processes of fermentation and decay, causing bloating and colic in the baby. Gastroesophageal reflux of a physiological nature protects the child's body from overeating and pain.

By the age of one, the child's digestive system is almost completely formed: the mucous membrane, enzyme production, sphincter, however, the muscular layer of the gastrointestinal tract is poorly developed. By 12-18 months, the baby completely stops the physiological reflux manifestation, except for pathological abnormalities.

Risk factors for the pathological development of GER

Gastroesophageal reflux, which is a consequence of pathological conditions in the gastrointestinal tract and does not go away for a long time, is diagnosed as gastroesophageal reflux disease (GERD).

Congenital anomalies associated with gastroesophageal reflux in children under 1 year old are the result of:

• premature birth;
• transferred intrauterine oxygen deficiency of the fetus (hypoxia);
• suffocation of a newborn as a result of oxygen starvation and excessive accumulation of carbon dioxide in the blood and tissues (asphyxia);
• birth injury of the cervical spine;
• inflammatory processes in the gastrointestinal tract;
• pathological development of the esophagus;
• diseases of the upper digestive system at the genetic level, including GERD;
• improper lifestyle of the mother during pregnancy.

Gastroesophageal reflux disease is often an acquired pathological condition in children and occurs as a result of:

1. lactose intolerance due to low levels of the enzyme lactase, which helps to digest it;
2. food allergies, mostly intolerance to cow's milk proteins;
3. malnutrition of the mother during lactation;
4. early artificial feeding;
5. long-term treatment with anti-inflammatory drugs and drugs that include theophylline;
6. improper diet;
7. reduced immune system;
8. infectious diseases caused by candida fungi, herpes, cytomegalovirus;
9. diseases of the gastrointestinal tract: gastritis, peptic ulcer, stool disorders.

IMPORTANT! A common cause of acquired GER in a child is overfeeding, as a result of which excess stomach contents press on the esophageal sphincter, disrupting its functionality in the future.

Reviews of specialists about gastroesophageal reflux in children. What can be caused by congenital and acquired pathology. Symptoms and preventive measures.

Symptoms of GER in newborns

Determining the cause of GER in young children is quite difficult, because they cannot tell what is bothering and how exactly one can only guess from the symptoms and observations of parents.

Symptoms of gastroesophageal reflux in children:

• frequent regurgitation;
• belching;
• vomiting of undigested food;
• hiccups
• uncomfortable burning sensations in the stomach and esophagus;
• stool disorders;
• increased gas formation;
• weight loss;
• constant crying and restlessness after eating.

In the early stages of development, GERD may be asymptomatic.

GERD classification

Gastroesophageal reflux disease is divided into:

• flow form;
• severity;
• varieties.

Forms of gastroesophageal reflux disease

GERD is divided into 2 forms:

1. acute resulting from improper functionality of the gastrointestinal tract. With this form, the child is sore, lack of appetite, weakness.
2. chronic, which is a consequence of diseases of the digestive system. It can occur on its own with malnutrition.

Degrees of expression

According to the degree of development, the gastroesophageal disease is divided into 4 stages:

• 1st stage has mild symptoms or is asymptomatic. In the process of development of the pathology, irritation, swelling and redness of the mucous membrane of the esophagus occur, tiny erosions from 0.1 to 2.9 mm appear.
• 2nd stage manifests itself in the form of heartburn, pain and heaviness after eating. Ulcers from 3 to 6 mm are formed in the esophagus, which affect the mucous membrane, giving the child discomfort.
• 3rd stage manifested by severe symptoms: pain when swallowing, a regular burning sensation in the chest, feelings of heaviness and pain in the stomach. Ulcers form a common lesion of the esophageal mucosa by 70%.
• 4th stage is a painful and dangerous crumb that can degenerate into cancerous ailments. The esophagus is affected by more than 75% of the total mass. The child is constantly worried about pain.

Gastroesophageal disease is diagnosed in 90% of cases at the second stage, when the symptoms become pronounced. The last stages of development can be cured with the help of surgery.

Varieties of GERD

Due to the occurrence of the disease, gastroesophageal disease is divided into varieties:

1. catarrhal- during which there is a violation of the mucous membrane of the esophagus due to the ingress of acidic stomach contents;
2. edematous- in the process, the esophagus narrows, its walls thicken and the mucous membrane swells;
3. exofoliative- which is a complex pathological process, as a result of which the high molecular weight fibrin protein is separated, which leads to hemorrhages, severe pain and coughing;
4. pseudomembranous- accompanied by nausea and vomiting, the mass of which contains grayish-yellow film components of fibrin;
5. ulcerative- the most complex form, occurring with ulcerative lesions and curable only by surgery.

With frequent and regular complaints of the child, it is urgent to consult a doctor.

Complications after GERD

Since the symptoms of reflux may not appear immediately, it is quite difficult to prescribe timely treatment for a child. As a result of a neglected disease, complex pathological processes occur:

• burns of the esophageal mucosa with gastric contents;
• beriberi against the background of a decrease in appetite and a lack of nutrients, weight loss;
• changes in the physiological form of the esophagus, leading to chronic diseases of the gastrointestinal tract: ulcers, oncology;
• pneumonia and / or asthma resulting from the penetration of the contents of the stomach into the respiratory tract;
• dental ailments, mainly damage to tooth enamel with hydrochloric acid.

Frequent hiccups or belching may indicate gastroesophageal reflux in a child. Not every pediatrician will be able to determine this ailment. If you experience these symptoms regularly, ask your pediatrician for a referral to a specialist gastroenterologist.

Diagnostics

Diagnostic measures to detect GERD include:

1. endoscopic examination method - helps to identify pathological inflammatory conditions in the esophagus from changes in the mucous membrane to hemorrhages;
2. histological examination (biopsy) allows you to detect cellular changes in the epithelium, as a result of the influence of previous diseases;
3. manometric examination, which allows measuring the pressure inside the esophageal lumen and assessing the motor activity and functionality of both valves of the esophagus;
4. the pH level research technique is able to determine the daily number and duration of refluxes;
5. X-ray diagnostics helps to detect an esophageal ulcer, narrowing of the lumen and a hernia of the diaphragm opening.

Diagnosis of GERD can be prescribed both in a clinic and in a hospital.

Prevention and treatment of GERD

For the treatment of gastroesophageal disease, experts recommend complex treatment. Depending on the symptoms and stage of development of the disease, apply:

• correct mode;
• drug treatment;
• surgical intervention.

The correct regimen includes dietary nutrition - the obligatory observance of a fractional balanced diet. The last meal should be at least 3 hours before bedtime. You need to sleep in an elevated position, the head and chest should be 15-20 cm higher than the lower body. Make sure your child has loose clothing that does not compress the abdomen.

Advice! Do not force the child to eat by force, it is better to feed little by little, but more often.

Medical treatment has several directions:

1. normalization of the acid barrier - for this, antisecretory drugs are used: Rabenprazol, Omeprazole, Esomeprazole, Pantoprazole, Phosphalugel, Maalox, Almagel;
2. improvement of the motor activity of the esophageal system is achieved by increasing the gastrointestinal tract statics with the help of drugs "Domperidone" and "Metoclopramide";
3. restoration of the mucous membrane of the esophagus occurs with the help of vitamins: pantothenic acid (B5) and methylmethionine sulfonium chloride.

With the help of drug therapy, pain relief, recovery, locking of the esophageal valve and a reduction in the release of hydrochloric acid occur.

Surgical intervention is used in the last stages of the development of gastroesophageal disease after a complete examination of the patient, taking into account the recommendations of doctors in different areas: gastroenterologists, cardiologists, anesthesiologists, surgeons. The operation is prescribed in cases where drug treatment does not help for a long time or the pathological process has caused severe harm to the body.