Cardio-Esophageal Relaxation as a Cause of Vomiting in Infants

Persistent or recurrent vomiting in the newborn or young infant occurs as a frequent problem in pediatric care. This disturbance may be produced by a variety of causes that need not be enumerated here. A large percentage of cases are due to parenteral factors and are usually not subjected to radiologic examination. There remain a considerable number of patients in whom, because of the repeated and significant nature of the vomiting, roentgenologic examination is warranted. Among this group we have observed, in the past three years, 12 patients who exhibited persistent vomiting evidently due to relaxation or dysfunction of the hiatus portion of the esophagus with failure of the normal "sphincter" action of the cardia. In only one instance have we seen this condition beyond the neonatal period. This was in a boy of four who had vomited many feedings and many meals since birth. Berk (2) has reported the case of an adult with a similar clinical and radiographic picture. Because in many respects the condition appears to be the opposite of achalasia of the esophagus, we frequently have referred to the persistent relaxation as "chalasia." The etiology of this condition is not certain, and one can only speculate as to its probable cause. The normal hiatus esophagus does not gape, but is closed by the pinchcock action of the diaphragm (4). One could postulate that this type of persistent relaxation might be the result of failure of the pinchcock mechanism to function adequately, due to failure of proper development or to imbalance of neuromuscular control. The sphincter-like muscular tonicity at the level of the diaphragm must be relaxed to allow the passage of food into the stomach, but if an appreciably relaxed state is allowed to remain, there will be a reflux of gastric contents into the esophagus and regurgitation will result. The cardiac sphincter is kept normally closed. The nervous control of the cardia is such that vagal stimulation or sympathetic inhibition results in relaxation of the cardia, while vagal inhibition or sympathetic stimulation produces contraction. The tone of the cardia may also be inhibited by mild stimulation of the gastric mucosa or by sensory impulses arising in the mouth and pharynx. If, as has been postulated, achalasia or cardiospasm may be produced by sympathetic-parasympathetic imbalance, there is no reason to doubt that the same forces operating in the opposite direction may result in chalasia or relaxation of the cardia. Indeed, the surprising thing is that it has not been observed more often. As there have been no deaths in this series, we have not had the opportunity to observe whether there is any visible failure or lack of development to account for this difficulty. The clinical story is usually well defined. The disease is seen with equal frequency among both male and female infants. The patient almost invariably starts vomiting within a week after birth, usually during the first few days of life.