gastro-jРоссийский журнал гастроэнтерологии, гепатологии, колопроктологииRussian Journal of Gastroenterology, Hepatology, Coloproctology1382-43762658-6673«Gastro» LLC10.22416/1382-4376-2024-34-6-120-148gastro-j-1262Research ArticleКЛИНИЧЕСКИЕ РЕКОМЕНДАЦИИ РОССИЙСКОЙ ГАСТРОЭНТЕРОЛОГИЧЕСКОЙ АССОЦИАЦИИCLINICAL GUIDELINES OF THE RUSSIAN GASTROENTEROLOGICAL ASSOCIATIONДиагностика и лечение ахалазии кардии (Клинические рекомендации Российской гастроэнтерологической ассоциации, Российского научного медицинского общества терапевтов, Российского общества профилактики неинфекционных заболеваний, Ассоциации эндоскопического общества «РЭндО» (Российского эндоскопического общества))Diagnostics and Treatment of Esophageal Achalasia (Clinical Guidelines of the Russian Gastroenterological Association, Russian Scientific Medical Society of Internal Medicine, Russian Society for the Prevention of Noncommunicable Diseases, REndO Endoscopic Society)https://orcid.org/0000-0002-6815-6015ИвашкинВ. Т.IvashkinV. T.

Ивашкин Владимир Трофимович — доктор медицинских наук, профессор, академик РАН, заведующий кафедрой пропедевтики внутренних болезней, гастроэнтерологии и гепатологии

119435, г. Москва, ул. Погодинская, 1, стр. 1

Vladimir T. Ivashkin — Dr. Sci. (Med.), Professor, Academician of the Russian Acaemy of Sciences, Head of the Department of Propaedeutics of Internal Diseases, Gastroenterology and Hepatology

119435, Moscow, Pogodinskaya str., 1, build. 1 

ivashkin_v_t@staff.sechenov.ruhttps://orcid.org/0000-0003-3362-2968ТрухмановА. С.TrukhmanovA. S.

Трухманов Александр Сергеевич — доктор медицинских наук, профессор кафедры пропедевтики внутренних болезней, гастроэнтерологии и  гепатологии

119435, г. Москва, ул. Погодинская, 1, стр. 1

Alexander S. Trukhmanov — Dr. Sci. (Med.), Professor of the Department of Propaedeutics of Internal Diseases, Gastroenterology and Hepatology

119435, Moscow, Pogodinskaya str., 1, build. 1 

alexander.trukhmanov@gmail.comhttps://orcid.org/0000-0001-6114-564XМаевИ. В.MaevI. V.

Маев Игорь Вениаминович — доктор медицинских наук, профессор, академик РАН, заведующий кафедрой пропедевтики внутренних болезней и гастроэнтерологии

127473, г. Москва, ул. Делегатская, 20, стр. 1

Igor V. Maev — Dr. Sci. (Med.), Professor, Academician of the Russian Academy of Medical Sciences, Head of the Department of Propaedeutics of Internal Diseases and Gastroenterology

127473, Moscow, Delegatskaya str., 20, build. 1 

igormaev@rambler.ruhttps://orcid.org/0000-0002-4453-8430ДрапкинаО. М.DrapkinaO. M.

Драпкина Оксана Михайловна — доктор медицинских наук,профессор, академик РАН, директор; главный внештатный специалистпо терапии и общемедицинской практике Минздрава России

101990, г. Москва, Петроверигский пер., 10, стр. 3

Oksana M. Drapkina — Dr. Sci. (Med.), Professor, Academician of the Russian Academy of Medical Sciences, Director; Chief External Specialist in Therapy and General Medical Practice of the Ministry of Health of Russia

101990, Moscow, Petroverigsky lane, 10, build. 3 

drapkina@bk.ruМартыновА. И.MartynovA. I.

Мартынов Анатолий Иванович — доктор медицинских наук, академик РАН, профессор кафедры госпитальной терапии № 1; Президент Российского научного медицинского общества терапевтов

127473, г. Москва, ул. Делегатская, 20, стр. 1 

Anatoliy I. Martynov — Dr. Sci. (Med.), Academician of the Russian Academy of Medical Sciences, Professor of the Department of Hospital Therapy; President of Russian Scientific Medical Society of Internal Medicine

127473, Moscow, Delegatskaya str., 20, build. 1 

anatmartynov@mail.ruhttps://orcid.org/0000-0002-0960-1166СтороноваО. А.StoronovaO. A.

Сторонова Ольга Андреевна — кандидат медицинских наук, врач отделения функциональной диагностики клиники пропедевтики  внутренних болезней, гастроэнтерологии и гепатологии им. В.Х. Василенко

119435, г. Москва, ул. Погодинская, 1, стр. 1

Olga A. Storonova — Cand. Sci. (Med.), Physician at the Department of Functional Diagnostics, V.Kh. Vasilenko Clinic of Internal Diseases Propaedeutics, Gastroenterology and Hepatology

119435, Moscow, Pogodinskaya str., 1, build. 1 

storonova_o_a@staff.sechenov.ruhttps://orcid.org/0000-0001-5320-788XГоджеллоЭ. А.GodgelloE. A.

Годжелло Элина Алексеевна — доктор медицинских наук, главный научный сотрудник эндоскопического отделения; член Ассоциации эндоскопического общества «РЭндО» (Российское эндоскопическое общество)

119435, г. Москва, Абрикосовский пер., 2. 

Elina A. Godgello — Dr. Sci. (Med.), Chief Researcher at the Department of  Endoscopy; Member of the Association of Russian Endoscopy Society

119435, Moscow, Abrikosovsky lane, 2 

godjello@inbox.ruhttps://orcid.org/0000-0001-5061-0139КоролевМ. П.KorolevM. P.

Королев Михаил Павлович — доктор медицинских наук, заведующий кафедрой общей хирургии с курсом эндоскопии

119014, г. Санкт-Петербург, Литейный просп., 56

Mikhail P. Korolev — Dr. Sci. (Med.), Head of the Department of General Surgery with an Endoscopy Course

119014, Saint Petersburg, Liteiny ave., 56 

korolevmp@yandex.ruhttps://orcid.org/0000-0003-4456-8725ЛапинаТ. Л.LapinaT. L.

Лапина Татьяна Львовна — кандидат медицинских наук, доцент кафедры пропедевтики внутренних болезней, гастроэнтерологии и гепатологии

119435, г. Москва, ул. Погодинская, 1, стр. 1

Tatiana L. Lapina — Cand. Sci. (Med.), Associate Professor at the Department of Propaedeutics of Internal Diseases, Gastroenterology and Hepatology

119435, Moscow, Pogodinskaya str., 1, build. 1 

tatlapina@gmail.comhttps://orcid.org/0000-0002-4391-5441ПавловП. В.PavlovP. V.

Павлов Павел Владимирович — кандидат медицинских наук, доцент кафедры хирургии Института клинической медицины им. Н.В. Склифосовского, заведующий отделением диагностической и лечебной эндоскопии Университетской клинической больницы № 2

119435, г. Москва, ул. Погодинская, 1, стр. 1

Pavel V. Pavlov — Cand. Sci. (Med.), Associate Professor at the Department of Surgery of N.V. Sklifosovsky Institute of Clinical Medicine, Head of the Department of Diagnostic and Therapeutic Endoscopy of the University Clinical Hospital No. 2

119435, Moscow, Pogodinskaya str., 1, build. 1 

pavlov_p_v@staff.sechenov.ruhttps://orcid.org/0000-0002-1662-2352ПараскевоваА. В.ParaskevovaA. V.

Параскевова Анна Владимировна — кандидат медицинских наук, врач отделения функциональной диагностики клиники пропедевтики  внутренних болезней, гастроэнтерологии и гепатологии им. В.Х. Василенко

119435, г. Москва, ул. Погодинская, 1, стр. 1 

Anna V. Paraskevova — Cand. Sci. (Med.), Physician at the Department of Functional Diagnostics, V.Kh. Vasilenko Clinic of Internal Diseases Propaedeutics, Gastroenterology and Hepatology

119435, Moscow, Pogodinskaya str., 1, build. 1 

paraskevova_a_v@staff.sechenov.ruhttps://orcid.org/0000-0001-9344-7351ТарасоваИ. А.TarasovaI. A.

Тарасова Ирина Александровна — кандидат медицинских наук, старший научный сотрудник отделения торакоабдоминальной хирургии и  онкологии; доцент кафедры госпитальной хирургии № 2 Института клинической медицины им. Н.В. Склифосовского, ФГАОУ ВО «Первый Московский государственный медицинский университет им. И.М. Сеченова»

119435, г. Москва, ул. Большая Пироговская, 2 

Irina A. Tarasova — Cand. Sci. (Med.), Senior Researcher at the Department of Thoracoabdominal Surgery and Oncology, Petrovsky National Research Centre of Surgery; Associate Professor of the Department of Hospital Surgery No. 2

119435, Moscow, Abricosovsky lane, 2 

tarasova_i_a@staff.sechenov.ruhttps://orcid.org/0000-0002-6036-7061ФедоровЕ. Д.FedorovE. D.

Федоров Евгений Дмитриевич — доктор медицинских наук, профессор, главный научный сотрудник научно-исследовательской лаборатории хирургической гастроэнтерологии и эндоскопии; клинический руководитель отделения эндоскопической хирургии; Председатель правления Ассоциации эндоскопического общества «РЭндО» (Российское эндоскопическое общество)

117997, г. Москва, ул. Островитянова, 1 

Evgeny D. Fedorov — Dr. Sci. (Med.), Professor, Chief Researcher at the Research Laboratory of Surgical Gastroenterology and Endoscopy; Clinical Head of the Department of Endoscopic Surgery;  Chairman of the Board of the Association of Endoscopic Society “REndO” (Russian Endoscopic Society)

117997, Moscow, Ostrovityanova str., 1 

efedo@mail.ruhttps://orcid.org/0000-0002-4445-2530ЦховребовА. Т.TskhovrebovA. T.

Цховребов Александр Теймуразович — научный сотрудник отделения торакоабдоминальной хирургии и онкологии

119435, г. Москва, Абрикосовский пер., 2 

Alexander T. Tskhovrebov — Researcher at the Department of Thoracoabdominal Surgery and Oncology

119435, Moscow, Abrikosovsky lane, 2 

pnrc-alex@mail.ruhttps://orcid.org/0000-0003-2742-7795ШапкаМ. П.ShapkaM. P.

Шапка Маргарита Петровна — врач-рентгенолог отделения лучевой диагностики клиники пропедевтики внутренних болезней, гастроэнтерологии и гепатологии им. В.Х. Василенко

119435, г. Москва, ул. Погодинская, 1, стр. 1 

Margarita P. Shapka — Radiologist of the Department of Radiation Diagnostics,  V.Kh. Vasilenko Clinic of Internal Diseases Propedeutics, Gastroenterology and Hepatology

119435, Moscow, Pogodinskaya str., 1, build. 1 

shapka_m_p@staff.sechenov.ruhttps://orcid.org/0000-0003-3387-7442ШестаковА. Л.ShestakovA. L.

Шестаков Алексей Леонидович — доктор медицинских наук, профессор, заведующий отделением торакоабдоминальной хирургии и онкологии, ФГБНУ «Российский научный центр хирургии имени академика Б.В. Петровского»

119435, г. Москва, Абрикосовский пер., 2 

Aleksey L. Shestakov — Dr. Sci. (Med.), Head of the Departmental of  Thoracoabdominal Surgery and Oncology

119435, Moscow, Abrikosovsky lane, 2 

221161@mail.ruhttps://orcid.org/0000-0003-3091-7402ЮрасовА. В.YurasovA. V.

Юрасов Анатолий Владимирович — доктор медицинских наук, главный научный сотрудник отделения торакоабдоминальной хирургии и онкологии

119435, г. Москва, Абрикосовcкий пер., 2

Anatolii V. Yurasov — Dr. Sci. (Med.), Chief Researcher of the Departmental of Thoracoabdominal Surgery and Oncology

119435, Moscow, Abrikosovsky lane, 2 

ayurasov@mail.ruФГАОУ ВО «Первый Московский государственный медицинский университет им. И.М. Сеченова» (Сеченовский Университет) Министерства здравоохранения Российской ФедерацииРоссияI.M. Sechenov First Moscow State Medical University (Sechenov University)Russian FederationФГБОУ ВО «Российский университет медицины» Министерства здравоохранения Российской ФедерацииРоссияRussian University of MedicineRussian FederationФГБУ ВО «Национальный медицинский исследовательский центр терапии и профилактической медицины» Министерства здравоохранения Российской ФедерацииРоссияNational Medical Research Center for Therapy and Preventive MedicineRussian FederationФГБНУ «Российский научный центр хирургии имени академика Б.В. Петровского»РоссияPetrovsky National Research Center of SurgeryRussian FederationФГБОУ ВО «Санкт-Петербургский государственный педиатрический медицинский университет» Министерства здравоохранения Российской ФедерацииРоссияSaint Petersburg State Pediatric Medical UniversityRussian FederationФГАОУ ВО «Российский национальный исследовательский медицинский университет имени Н.И. Пирогова» Министерства здравоохранения Российской Федерации; ГБУЗ «Городская клиническая больница № 31 им. академика Г.М. Савельевой» Департамента здравоохранения города МосквыРоссияN.I. Pirogov Russian National Research Medical University; City Clinical Hospital No. 31 named after Academician G.M. Savelyeva of Moscow City Health DepartmentRussian Federation202430122024346120148Copyright © Ивашкин В.Т., Трухманов А.С., Маев И.В., Драпкина О.М., Мартынов А.И., Сторонова О.А., Годжелло Э.А., Королев М.П., Лапина Т.Л., Павлов П.В., Параскевова А.В., Тарасова И.А., Федоров Е.Д., Цховребов А.Т., Шапка М.П., Шестаков А.Л., Юрасов А.В., 20252025Ивашкин В.Т., Трухманов А.С., Маев И.В., Драпкина О.М., Мартынов А.И., Сторонова О.А., Годжелло Э.А., Королев М.П., Лапина Т.Л., Павлов П.В., Параскевова А.В., Тарасова И.А., Федоров Е.Д., Цховребов А.Т., Шапка М.П., Шестаков А.Л., Юрасов А.В.Ivashkin V.T., Trukhmanov A.S., Maev I.V., Drapkina O.M., Martynov A.I., Storonova O.A., Godgello E.A., Korolev M.P., Lapina T.L., Pavlov P.V., Paraskevova A.V., Tarasova I.A., Fedorov E.D., Tskhovrebov A.T., Shapka M.P., Shestakov A.L., Yurasov A.V.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.gastro-j.ru/jour/article/view/1262

Цель: ознакомить врачей-гастроэнтерологов, терапевтов, врачей функциональной диагностики и общей практики (семейных врачей), рентгенологов, эндоскопистов с современными методами диагностики и лечения ахалазии кардии.Основное содержание. Ахалазия кардии — идиопатическое нервно-мышечное заболевание, проявляющееся функциональным нарушением проходимости кардии вследствие дискоординации между глотком, рефлекторным раскрытием нижнего пищеводного сфинктера, двигательной и тонической активностью гладкой мускулатуры пищевода. В настоящее время этиология ахалазии кардии остается до конца не ясной. Однако считается, что изменения в миэнтеральном (ауэрбаховом) межмышечном сплетении энтеральной нервной системы пищевода, ведущие к потере функции нейронов, играют ключевую роль. В качестве основных механизмов развития ахалазии кардии предложены следующие гипотезы: генетическая предрасположенность, воздействие вирусных инфекций и идиопатические аутоиммунные триггеры. Пациентам с подозрением на ахалазию кардии необходимо проведение комплексного инструментального обследования, включающего в себя эзофагогастродуоденоскопию, рентгенологическое исследование с бариевой взвесью по методике хронометрированной контрастной рентгенографии, манометрию пищевода. В последние годы «золотым стандартом» диагностики ахалазии кардии признана манометрия пищевода высокого разрешения. Для проведения анализа полученных данных рекомендована Чикагская классификация, позволяющая определить развившийся у пациента тип ахалазии кардии, от чего зависит выбор метода лечения заболевания и оценка прогноза эффективности терапии. Лечение ахалазии кардии может быть медикаментозным, эндоскопическим (баллонная пневмодилатация, пероральная эндоскопическая миотомия, инъекция ботулинического токсина), направленным на регулирование тонуса и моторики пищевода и кардии с сохранением всех анатомических структур, и хирургическим (лапароскопическая эзофагокардиомиотомия, эзофагэктомия), при котором пересекаются мышечные волокна пищевода и пищеводно-желудочного перехода или полностью удаляется измененный пищевод с одномоментным формированием искусственного пищевода из желудка или толстой кишки (эзофагопластикой).Заключение. Выполнение разработанных клинических рекомендаций позволит своевременно установить диагноз, что приведет к улучшению качества оказания медицинской помощи пациентам с ахалазией кардии.

Aim: to familiarize gastroenterologists, therapists, functional diagnostics and general practitioners (family doctors), radiologists, and endoscopists with modern methods of diagnosis and treatment of achalasia of the cardia.Key points. Achalasia is an idiopathic neuromuscular disease manifested by a functional disorder of the patency of the cardia due to a lack of coordination between swallowing, reflex opening of the lower esophageal sphincter, and the motor and tonic activity of the smooth muscles of the esophagus. The etiology of achalasia remains unclear. However, it is believed that the key role belongs to the changes in the myenteric (Auerbach’s) intermuscular plexus of the enteric nervous system of the esophagus, leading to loss of neuronal function. The following hypotheses have been proposed as the main mechanisms for the development of achalasia: genetic predisposition, exposure to viral infections, and idiopathic autoimmune triggers. Patients with suspected achalasia require a comprehensive instrumental examination, including esophagogastroduodenoscopy, timed barium esophagogram, and esophageal manometry. In recent years, high-resolution esophageal manometry has been recognized as the gold standard for achalasia diagnostics. To analyse the obtained data, the Chicago classification is recommended — it allows to ascertain the type of achalasia, which determines the choice of treatment method and the assessment of the prognosis of the therapy effectiveness. Treatment of achalasia can be pharmacological, endoscopic (pneumatic balloon dilation, peroral endoscopic myotomy, botulinum toxin injection), aimed at regulating the tone and motility of the esophagus and cardia while preserving all anatomical structures, and surgical (laparoscopic esophagocardiomyotomy, esophagectomy), in which the muscle fibers of the esophagus and esophagogastric junction are intersected or the altered esophagus is completely removed with simultaneous formation of an artificial esophagus from the stomach or colon (esophagoplasty).Conclusion. Implementation of the developed clinical guidelines can help to establish a diagnosis in a timely manner, which will lead to an improvement in the quality of medical care for patients with achalasia.

ахалазия кардиикардиоспазмнижний пищеводный сфинктердискинезия пищеводадисфагияболь в грудной клеткеэзофагитрак пищеводапсевдоахалазиядиагностикаманометрия пищевода высокого разрешениярентген пищевода с сульфатом барияхронометрированная контрастная рентгенографиябаллонная пневмодилатация кардиипероральная эндоскопическая миотомиялапароскопическая эзофагокардиомиотомиялечениеachalasiacardiospasmlower esophageal sphincteresophageal dyskinesiadysphagiachest painesophagitisesophageal cancerpseudoachalasiadiagnosticshigh-resolution esophageal manometrybarium sulfate esophageal X-raytimed barium esophagogrampneumatic balloon dilation of the cardiaperoral endoscopic myotomylaparoscopic esophagocardiomyotomytreatmentReferencesAtes M.F., Vaezi F. The pathogenesis and management of achalasia: Current status and future directions. Gut Liver. 2015;9(4):449–63. DOI: 10.5009/gnl14446Ates M.F., Vaezi F. The pathogenesis and management of achalasia: Current status and future directions. 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The authors declare that there are no conflicts of interest present.