{"id":241,"date":"2013-03-14T09:35:57","date_gmt":"2013-03-14T09:35:57","guid":{"rendered":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=241"},"modified":"2013-06-09T13:08:04","modified_gmt":"2013-06-09T13:08:04","slug":"5-3","status":"publish","type":"page","link":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=241","title":{"rendered":"5 Anatomie a fyziologie j\u00edcnu"},"content":{"rendered":"

5.1 Anatomick\u00e1 a funk\u010dn\u00ed definice<\/h3>\n
\"Obr.<\/a>

Obr. 1
Anatomick\u00e9 \u010dlen\u011bn\u00ed j\u00edcnu a jeho topografick\u00e9 vztahy k okol\u00ed. Vlevo: p\u0159ibli\u017en\u00e1 vzd\u00e1lenost od \/ horn\u00edch \u0159ez\u00e1k\u016f, I, II, III \u2013 fyziologick\u00e1 z\u00fa\u017een\u00ed j\u00edcnu<\/p><\/div>\n

J\u00edcen je svalov\u00e1 trubice spojuj\u00edc\u00ed farynx se \u017ealudkem, kter\u00e1 zaji\u0161\u0165uje transport potravy a sekret\u016f mezi t\u011bmito dv\u011bma org\u00e1ny.<\/p>\n

V klidu je j\u00edcen pr\u00e1zdn\u00fd a obsah patogenn\u00edch mikrob\u016f je d\u00e1n komunikac\u00ed s dutinou \u00fastn\u00ed a potravou. Ezofagus za\u010d\u00edn\u00e1 ve v\u00fd\u0161i cartilago cricoidea, co\u017e odpov\u00edd\u00e1 6.-7. kr\u010dn\u00edmu obratli. V kr\u010dn\u00edm \u00faseku prob\u00edh\u00e1 v\u00edce vlevo, nal\u00e9h\u00e1 na p\u00e1te\u0159 a jeho svalstvo je ventr\u00e1ln\u011b v \u00fazk\u00e9m vztahu k pr\u016fdu\u0161nici a abor\u00e1ln\u011bji k lev\u00e9mu bronchu. Ve \u017el\u00e1bku mezi tracheou a j\u00edcnem prob\u00edh\u00e1 vratn\u00fd nerv. V hrudn\u00edku vytv\u00e1\u0159\u00ed aort\u00e1ln\u00ed oblouk na j\u00edcnu r\u016fzn\u011b v\u00fdraznou impresi zleva a sestupn\u00e1 aorta ho prov\u00e1z\u00ed d\u00e1le po jeho lev\u00e9 stran\u011b. Na j\u00edcen zde nal\u00e9h\u00e1 levostrann\u00e1 mediastin\u00e1ln\u00ed pleura. V doln\u00edm mezihrud\u00ed zah\u00fdb\u00e1 j\u00edcen pon\u011bkud ventr\u00e1ln\u011bji a doleva, proch\u00e1z\u00ed br\u00e1nic\u00ed v hiatus oesophageus, le\u017e\u00edc\u00ed p\u0159ed hi\u00e1tem aort\u00e1ln\u00edm (obr. 1).<\/p>\n

Na obou konc\u00edch je j\u00edcen opat\u0159en sfinktery: horn\u00ed, krikofarynge\u00e1ln\u00ed, je v klidu uzav\u0159en a br\u00e1n\u00ed vstupu vzduchu p\u0159i d\u00fdch\u00e1n\u00ed, doln\u00ed j\u00edcnov\u00fd sv\u011bra\u010d, kter\u00fd nen\u00ed v\u00fdrazn\u011bji anatomicky definov\u00e1n, umo\u017e\u0148uje prostup sousta do \u017ealudku, ale br\u00e1n\u00ed zp\u011btn\u00e9mu toku \u017ealude\u010dn\u00edho obsahu do ezofagu.<\/p>\n

J\u00edcen se v\u00fdrazn\u011b odli\u0161uje svou stavbou a skladbou od ostatn\u00edch \u00fasek\u016f tr\u00e1vic\u00ed trubice. Nejpevn\u011bj\u0161\u00ed vrstvou st\u011bny j\u00edcnu je sliznice, jej\u00ed\u017e dokonal\u00e1 sutura mus\u00ed b\u00fdt provedena p\u0159i operaci s maxim\u00e1ln\u00ed pozornost\u00ed. Druh\u00fdm z\u00e1kladn\u00edm rozd\u00edlem je nep\u0159\u00edtomnost ser\u00f3zy, co\u017e p\u0159isp\u00edv\u00e1 k technick\u00e9 n\u00e1ro\u010dnosti a obt\u00ed\u017enosti j\u00edcnov\u00e9 chirurgie. Sliznice j\u00edcnu je slo\u017eena v pod\u00e9ln\u00e9 \u0159asy, co\u017e p\u016fsob\u00ed hv\u011bzdicovit\u00fd pr\u016fsvit ezofagu. Na povrchu je kryta mnohovrstevn\u00fdm dla\u017edicov\u00fdm epitelem. Svalovina j\u00edcnu je tvo\u0159ena v horn\u00ed t\u0159etin\u011b p\u0159ev\u00e1\u017en\u011b p\u0159\u00ed\u010dn\u011b pruhovan\u00fdm svalstvem, ve st\u0159edn\u00ed t\u0159etin\u011b postupn\u011b p\u0159ech\u00e1z\u00ed ve svalstvo hladk\u00e9, kter\u00fdm je tvo\u0159ena doln\u00ed t\u0159etina j\u00edcnu. Klasick\u00e1 anatomie rozli\u0161uje zevn\u00ed longitudin\u00e1ln\u00ed a vnit\u0159n\u00ed cirkul\u00e1rn\u00ed svalovinu. Podle M\u00fcllera [1] jsou ob\u011b vrstvy spojeny svalov\u00fdmi snopci, kter\u00e9 se m\u00edsty v\u011btv\u00ed a v z\u00e1vislosti na funk\u010dn\u00edm stavu vytv\u00e1\u0159ej\u00ed zk\u0159\u00ed\u017eenou m\u0159\u00ed\u017eovitou strukturu. Hlavn\u00ed svalov\u00e1 masa v\u0161ak zachov\u00e1v\u00e1 pod\u00e9ln\u00e9 a cirkul\u00e1rn\u00ed uspo\u0159\u00e1d\u00e1n\u00ed. Podle Stelznera a Lierse [2] je svalovina j\u00edcnu tvo\u0159ena apol\u00e1rn\u00edm syst\u00e9mem spir\u00e1ln\u00edch svalov\u00fdch vl\u00e1ken (viz kapitola 5.4.2.2, obr. 6). Arteri\u00e1ln\u00ed z\u00e1soben\u00ed j\u00edcnu je z okoln\u00edch arteri\u00ed. V horn\u00ed \u010d\u00e1sti z a. thyroidea inferior, a. subclavia, d\u00e1le z aa. intercostales, rr. bronchiales a rr. oesophagei z hrudn\u00ed aorty a v abdomin\u00e1ln\u00ed \u010d\u00e1sti z a. gastrica sin. a aa. phrenicae inferiores. Odtok \u017eiln\u00ed krve se uskute\u010d\u0148uje ze submuk\u00f3zn\u00edch pleten\u00ed do povrchn\u00edch plex\u016f a d\u00e1le do okoln\u00edch v\u00e9n (vv. thyroideae inf., vv. intercostales, v. azygos a hemiazygos a v. coronaria ventriculi) [1a]. J\u00edcen je inervov\u00e1n z obou nn. vagi a kr\u010dn\u00edho a hrudn\u00edho sympatiku.<\/p>\n

5.2 Faryngoezofage\u00e1ln\u00ed p\u0159echod<\/h3>\n

5.2.1 Anatomie<\/h4>\n
\"Obr.<\/a>

Obr. 2
Pohled na faryngoezofage\u00e1ln\u00ed p\u0159echod z dorz\u00e1ln\u00ed strany.
M. constrictor pharynx inferior:
PT \u2013 pars thyreopharingea
PO \u2013 pars obliqua
PF \u2013 pars fundiformis
MC \u2013 musculus cricopharyngeus
K \u2013 Kilian\u016fv troj\u00faheln\u00edk
L \u2013 Laimer\u016fv troj\u00faheln\u00edk<\/p><\/div>\n

Svalov\u00fd pl\u00e1\u0161\u0165 faryngu, kter\u00fd se rozprost\u00edr\u00e1 od b\u00e1ze lebn\u00ed do v\u00fd\u0161e C 6\u20137, kde p\u0159ech\u00e1z\u00ed v j\u00edcen, je tvo\u0159en svalov\u00fdmi vl\u00e1kny za\u010d\u00ednaj\u00edc\u00edmi z raphe pharyngis a prob\u00edhaj\u00edc\u00edmi p\u0159ev\u00e1\u017en\u011b \u0161ikmo shora zezadu obloukovit\u011b dop\u0159edu (obr. 2). Doln\u00ed \u010d\u00e1st tohoto svalov\u00e9ho masivu tvo\u0159\u00ed m. constrictor pharyngis inferior, \u010dlen\u00edc\u00ed se v pars thyropharyngea a pars cricopharyngea. Slo\u017eit\u00fd pr\u016fb\u011bh svalov\u00fdch\u00a0vl\u00e1ken pars cricopharyngea, kter\u00fd b\u00fdv\u00e1 ozna\u010dov\u00e1n t\u00e9\u017e jako m. cricopharyngeus, zde vytv\u00e1\u0159\u00ed sv\u00fdm \u010dlen\u011bn\u00edm na pars obliqua a pars fundiformis dv\u011b m\u00edsta s relativn\u011b oslabenou svalovinou \u2013 horn\u00ed Killian\u016fv a doln\u00ed Laimer\u016fv troj\u00faheln\u00edk. M. cricopharyngeusse up\u00edn\u00e1 ob\u011bma konci na cartilago cricoidea, \u0161\u00e1lovit\u011b obep\u00edn\u00e1 vstup j\u00edcnu a p\u0159i sv\u00e9 kontrakci uzav\u00edr\u00e1 vchod do ezofagu, a to tlakem proti prsten\u010dit\u00e9 chrupavce. Tento sval spolu s cirkul\u00e1rn\u00ed svalovinou po\u010d\u00e1tku j\u00edcnu vytv\u00e1\u0159\u00ed anatomick\u00fd substr\u00e1t horn\u00edho j\u00edcnov\u00e9ho sv\u011bra\u010de. Jeho inervaci obstar\u00e1vaj\u00ed vl\u00e1kna nn. vagi a z men\u0161\u00ed \u010d\u00e1sti IX. a XI. hlavov\u00fd nerv. Podle Romana sympatick\u00e1 inervace jeho motoriku pravd\u011bpodobn\u011b neovliv\u0148uje [1].<\/p>\n

5.2.2 Fyziologie faryngoezofage\u00e1ln\u00edho transportu<\/h4>\n
\"Obr.<\/a>

Obr. 3
P\u0159ibli\u017en\u00e9 tlaky ve faryngu, oblasti HJS a kr\u010dn\u00edm j\u00edcnu b\u011bhem polykac\u00edho aktu<\/p><\/div>\n

Horn\u00ed j\u00edcnov\u00fd sv\u011bra\u010d (HJS) odd\u011bluje sv\u00fdm klidov\u00fdm nap\u011bt\u00edm dutinu \u00fastn\u00ed a farynx, kter\u00e9 komunikuj\u00ed se zevn\u00edm atmosf\u00e9rick\u00fdm tlakem, od j\u00edcnu, kde je v klidu negativn\u00ed tlak \u20130,266 a\u017e \u20131,064 kPa (\u20132 a\u017e \u20138 mm Hg). Existence HJS je dnes bezpe\u010dn\u011b prok\u00e1z\u00e1na nejen morfologick\u00fdmi, ale i rentgenologick\u00fdmi, elektromyografick\u00fdmi a zejm\u00e9na manometrick\u00fdmi studiemi. Od prvn\u00edch manometrick\u00fdch m\u011b\u0159en\u00ed proveden\u00fdch Fykem a Codem [3] v roce 1955 se zdokonalila manometrick\u00e1 technika zejm\u00e9na u\u017eit\u00edm perfundovan\u00fdch kat\u00e9tr\u016f. V oblasti HJS m\u016f\u017eeme identifikovat z\u00f3nu zv\u00fd\u0161en\u00e9ho tlaku v d\u00e9lce 35 mm s maximem v d\u00e9lce asi 10 mm. Nam\u011b\u0159en\u00e9 hodnoty [4] se pohybuj\u00ed v rozmez\u00ed 7,98\u201313,3 kPa (60\u2013100 mm Hg). M\u011b\u0159en\u00ed s perfundovan\u00fdm kat\u00e9trem s n\u011bkolika bo\u010dn\u00edmi otvory ve stejn\u00e9 v\u00fd\u0161i prokazuj\u00ed v sagit\u00e1ln\u00ed rovin\u011b asymetrii m\u011b\u0159en\u00fdch tlak\u016f. Ventr\u00e1ln\u011b a dorz\u00e1ln\u011b kolem 13,3 kPa (100 mm Hg), zprava a zleva 3,325\u20133,99 kPa (25\u201330 mm Hg). Tuto asymetrii si lze lehce vysv\u011btlit, uv\u011bdom\u00edme-li si, \u017ee m. cricopharyngeus komprimuje j\u00edcen proti prsten\u010dit\u00e9 chrupavce jako smy\u010dka, a t\u00edm vytv\u00e1\u0159\u00ed uz\u00e1v\u011br vstupu do j\u00edcnu jako nap\u0159\u00ed\u010d prob\u00edhaj\u00edc\u00ed \u0161t\u011brbinu.<\/p>\n

P\u0159i polykac\u00edm aktu doch\u00e1z\u00ed k voln\u00edmu posunu sousta zpracovan\u00e9ho v \u00fastech sm\u011brem do hltanu (f\u00e1ze or\u00e1ln\u00ed). Kontakt sousta s hltanem vyvol\u00e1v\u00e1 v\u016fl\u00ed neovladateln\u00fd reflex p\u0159esunuj\u00edc\u00ed sousto do j\u00edcnu za sou\u010dasn\u00e9ho uz\u00e1v\u011bru dutiny nosn\u00ed a faryngu (f\u00e1ze farynge\u00e1ln\u00ed) a ve f\u00e1zi ezofage\u00e1ln\u00ed je sousto transportov\u00e1no do \u017ealudku. Velmi d\u016fle\u017eit\u00e1 je funk\u010dn\u00ed koordinace a n\u00e1vaznost kontrakce a relaxace jednotliv\u00fdch svalov\u00fdch skupin, proto\u017ee na polykac\u00edm aktu se ve faryngoezofage\u00e1ln\u00ed f\u00e1zi pod\u00edl\u00ed v\u00edce jak\u00a030 jednotliv\u00fdch sval\u016f inervovan\u00fdch p\u011bti hlavov\u00fdmi nervy. P\u0159i polyk\u00e1n\u00ed doch\u00e1z\u00ed b\u011bhem n\u011bkolika sekund ve faryngu, oblasti HJS a j\u00edcnu ke zna\u010dn\u00fdm tlakov\u00fdm v\u00fdkyv\u016fm a sousto je doslova vyst\u0159elov\u00e1no do j\u00edcnu pod tlakem, kter\u00fd m\u016f\u017ee v hypofaryngu dos\u00e1hnout hodnot 26,6\u201333,25 kPa (200\u2013250 mm Hg) t\u011bsn\u011b p\u0159ed relaxac\u00ed HJS, kter\u00e1 trv\u00e1 asi 0,8 sekundy [5] (obr. 3).<\/p>\n

5.3 Tubul\u00e1rn\u00ed j\u00edcen (t\u011blo j\u00edcnu)<\/h3>\n

V klidov\u00e9m stavu je j\u00edcen prakticky pr\u00e1zdn\u00fd, odd\u011blen\u00fd na obou konc\u00edch od sousedn\u00edch odd\u00edl\u016f za\u017e\u00edvac\u00edho traktu horn\u00edm a doln\u00edm j\u00edcnov\u00fdm sv\u011bra\u010dem. P\u0159i polyk\u00e1n\u00ed navazuje na farynge\u00e1ln\u00ed f\u00e1zi prim\u00e1rn\u00ed peristaltick\u00e1 kontrakce. Je vyvol\u00e1na polykac\u00edm aktem, prob\u011bhne postupn\u011b od faryngu a\u017e po termin\u00e1ln\u00ed j\u00edcen, p\u0159i\u010dem\u017e rychlost peristaltick\u00e9 vlny se v doln\u00ed \u010d\u00e1sti j\u00edcnu sni\u017euje. Sekund\u00e1rn\u00ed peristaltika vznik\u00e1 rozep\u011bt\u00edm j\u00edcnu soustem nebo jeho zbytkem a m\u016f\u017ee b\u00fdt vyvol\u00e1na i rozepjat\u00fdm balonem \u010di elektrick\u00fdm podr\u00e1\u017ed\u011bn\u00edm. Peristaltika za\u010d\u00edn\u00e1 proxim\u00e1ln\u011b od m\u00edsta podr\u00e1\u017ed\u011bn\u00ed, nej\u010dast\u011bji v horn\u00ed \u010d\u00e1sti ezofagu a prob\u011bhne postupn\u011b a\u017e ke kardii. Od t\u011bchto fyziologick\u00fdch typ\u016f peristaltiky je nutno odli\u0161ovat tzv. terci\u00e1rn\u00ed kontrakce. Neovliv\u0148uj\u00ed posun potravy, jsou stacion\u00e1rn\u00ed. Mohou vzniknout v r\u016fzn\u00fdch odd\u00edlech j\u00edcnu, \u010dast\u011bji v dist\u00e1ln\u00edch parti\u00edch. Vz\u00e1cn\u011b je m\u016f\u017eeme pozorovat bez klinick\u00e9 symptomatologie u zdrav\u00fdch jedinc\u016f, \u010dast\u011bj\u0161\u00ed jsou ve vy\u0161\u0161\u00edm v\u011bku a zpravidla jsou projevem patologick\u00fdch stav\u016f.<\/p>\n

5.4 Uz\u00e1v\u011brov\u00fd mechanizmus gastroezofage\u00e1ln\u00edho spojen\u00ed (GES)<\/h3>\n

5.4.1 Definice GES<\/h4>\n

P\u0159esto\u017ee od dob Galenov\u00fdch, kter\u00fd jako prvn\u00ed u\u017eil term\u00ednu kardie, uplynula v\u00edce jak dv\u011b tis\u00edcilet\u00ed, nen\u00ed vymezen\u00ed tohoto pojmu jednozna\u010dn\u011b definov\u00e1no [6, 7, 8]. V roce 1961 podal Hayward [9] z klinick\u00e9ho hlediska v\u00fdhodnou definici kardie (obr. 4).<\/p>\n

Or\u00e1ln\u011b ji ohrani\u010duje \u00fapon frenoezofage\u00e1ln\u00ed membr\u00e1ny a abor\u00e1ln\u011b \u0159asa peritonea, p\u0159ech\u00e1zej\u00edc\u00ed z br\u00e1nice na \u017ealudek. GES lze charakterizovat z r\u016fzn\u00fdch hledisek. Jin\u00e1 je definice anatomick\u00e1, histologick\u00e1, endoskopick\u00e1, manometrick\u00e1 nebo pH-metrick\u00e1.<\/p>\n

Vedle v\u00fdrazu kardie se setk\u00e1v\u00e1me s pojmenov\u00e1n\u00edm termin\u00e1ln\u00ed j\u00edcen [6, 10], gastroezofage\u00e1ln\u00ed junkce, \u00fasek, spojen\u00ed \u010di p\u0159echod [7, 11].<\/p>\n

GES funguje jako ventil, kter\u00fd umo\u017e\u0148uje voln\u00fd transport potravy do \u017ealudku a na druh\u00e9 stran\u011b chr\u00e1n\u00ed j\u00edcen p\u0159ed \u0161kodliv\u00fdm vlivem gastroezofage\u00e1ln\u00edho refluxu, ani\u017e by v\u0161ak zabra\u0148oval zvracen\u00ed \u010di od\u0159\u00edhnut\u00ed. V antirefluxn\u00edm mechanizmu (obr. 5) se prol\u00ednaj\u00ed prvky anatomick\u00e9 a funk\u010dn\u00ed.<\/p>\n\n\n\n
\"Obr.<\/a>

Obr. 4
Ezofagogastrick\u00e9 spojen\u00ed podle Haywarda [9] FM \u2013 frenoezofage\u00e1ln\u00ed membr\u00e1na je definice anatomick\u00e1, histologick\u00e1, endoskopick\u00e1, manometrick\u00e1 nebo pH-metrick\u00e1. Vedle v\u00fdrazu kardie se setk\u00e1v\u00e1me s pojmenov\u00e1n\u00edm termin\u00e1ln\u00ed j\u00edcen [6, 10], gastroezofage\u00e1ln\u00ed junkce, \u00fasek, spojen\u00ed \u010di p\u0159echod [7, 11]. GES funguje jako ventil, kter\u00fd umo\u017e\u0148uje voln\u00fd transport potravy do \u017ealudku a na druh\u00e9 stran\u011b chr\u00e1n\u00ed j\u00edcen p\u0159ed \u0161kodliv\u00fdm vlivem gastroezofage\u00e1ln\u00edho refluxu, ani\u017e by v\u0161ak zabra\u0148oval zvracen\u00ed \u010di od\u0159\u00edhnut\u00ed. V antirefluxn\u00edm mechanizmu (obr. 5) se prol\u00ednaj\u00ed prvky anatomick\u00e9 a funk\u010dn\u00ed.<\/p><\/div><\/td>\n

\n

\"Obr.<\/a>

Obr. 5
Jednotliv\u00e9 slo\u017eky antirefl exn\u00edho mechanizmu GES:
1 \u2013 doln\u00ed j\u00edcnov\u00fd sv\u011bra\u010d,
2 \u2013 \u201ekolabovateln\u00fd\u201c abdomin\u00e1ln\u00ed j\u00edcen a \u201efl utter
valve\u201c,
3 \u2013 His\u016fv \u00fahel a Gubaroff ova \u0159asa,
4 \u2013 fi xa\u010dn\u00ed apar\u00e1t GES (podrobn\u011b v textu),
5 \u2013 koordinace motility,
6 \u2013 ta\u017en\u00fd uz\u00e1v\u011br a fi brae obliquae,
7 \u2013 br\u00e1ni\u010dn\u00ed hi\u00e1tus,
8 \u2013 slizni\u010dn\u00ed rozeta.
Voln\u011b upraveno podle Bluma a Siewerta<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

.<\/span><\/p>\n

5.4.2 Doln\u00ed j\u00edcnov\u00fd sv\u011bra\u010d (DJS)<\/h4>\n

DJS je lokalizov\u00e1n v oblasti termin\u00e1ln\u00edho j\u00edcnu a je definov\u00e1n jako funk\u010dn\u00ed jednotka, postr\u00e1daj\u00edc\u00ed charakteristiky anatomick\u00e9ho sv\u011bra\u010de. Od okoln\u00ed svaloviny se odli\u0161uje p\u0159edev\u0161\u00edm zv\u00fd\u0161en\u00fdm nap\u011bt\u00edm a odli\u0161nou reakc\u00ed na hormon\u00e1ln\u00ed, farmakologick\u00e9 a nervov\u00e9 podn\u011bty [1].<\/p>\n

5.4.2.1 Manometrick\u00e1 charakteristika<\/h5>\n

Odd\u011blen\u00ed j\u00edcnu od \u017ealudku je dosa\u017eeno zv\u00fd\u0161en\u00fdm svalov\u00fdm tonusem DJS, jeho\u017e manometricky zjistiteln\u00fdm ekvivalentem je z\u00f3na zv\u00fd\u0161en\u00e9ho intralumin\u00e1ln\u00edho tlaku. Cohen, Harris a dal\u0161\u00ed auto\u0159i potvrdili, \u017ee intralumin\u00e1ln\u00ed tlak lze pova\u017eovat za vhodnou m\u00edru svalov\u00e9 kontrakce [12]. Maxim\u00e1ln\u00ed tlak sfinkteru v klidov\u00e9 f\u00e1zi, m\u011b\u0159en\u00fd Waldeckem zavedenou metodikou infuzn\u00edho kat\u00e9tru za kontinu\u00e1ln\u00edho tahu ze \u017ealudku do j\u00edcnu, kol\u00eds\u00e1 mezi 2,9\u20132,93 kPa (15\u201322 mm Hg); (nulov\u00e1 hodnota je tlak v \u017ealude\u010dn\u00edm fundu). D\u00e9lka z\u00f3ny zv\u00fd\u0161en\u00e9ho tlaku se v z\u00e1vislosti na d\u00fdch\u00e1n\u00ed pohybuje od 28 do 32 mm. Zji\u0161t\u011bn\u00e9 hodnoty kol\u00edsaj\u00ed podle pou\u017eit\u00e9 metody a jednotliv\u00fdch pracovi\u0161\u0165 [13, 14, 15] (tab. 1). Klidov\u00fd tlak se m\u011bn\u00ed p\u0159i polyk\u00e1n\u00ed, uplatn\u011bn\u00ed b\u0159i\u0161n\u00edho lisu, za patologick\u00fdch stav\u016f a podl\u00e9h\u00e1 hormon\u00e1ln\u00edm a farmakologick\u00fdm vliv\u016fm.<\/p>\n\n\n\n\n\n\n\n\n\n\n
Tab. 1
\nHodnoty intralumin\u00e1ln\u00edho tlaku v oblasti DJS u \u010dlov\u011bka<\/span>
\n(podle Waldecka a Jenneweina [1] <\/span>a na\u0161ich zku\u0161enost\u00ed [14]<\/span>)<\/span><\/td>\n<\/tr>\n
Manometrick\u00e1 metoda \u2013 autor<\/strong><\/td>\nKlidov\u00fd tlak DJS<\/strong><\/td>\n<\/tr>\n
Uzav\u0159en\u00fd kat\u00e9tr:<\/strong><\/td>\n<\/tr>\n
Fyke 1956
\nAffolter, Rossetti 1964
\nGilda 1969<\/td>\n		1,050 kPa (10,7 cm H2<\/span>O)
\n0,665 kPa (5,0 mm Hg)
\n1,158 \u00b1 0,118 kPa (11,8 \u00b1 1,2 cm H2<\/span>O)<\/td>\n<\/tr>\n
Infuzn\u00ed kat\u00e9tr:<\/strong><\/td>\n<\/tr>\n
Castell, Harris 1970
\nIsenberg 1971
\nCohen 1971
\nRoling 1972
\nWinans 1972<\/td>\n		2,0 \u00b1 1,57 kPa (15,0 \u00b1 11,7 mm Hg)
\n1,66 \u00b1 0,138 kPa (12,4 \u00b1 1,4 mm Hg)
\n2,58 \u00b1 0,135 kPa (19,4 \u00b1 1,3 mm Hg)
\n1,92 \u00b1 0,135 kPa (14,6 \u00b1 1,3 mm Hg)
\n2,98 \u00b1 0,400 kPa (22,7 \u00b1 3,1 mm Hg)<\/td>\n<\/tr>\n
Infuzn\u00ed kat\u00e9tr \u2013 kontinu\u00e1ln\u00ed tah:<\/strong><\/td>\n<\/tr>\n
Waldeck 1973
\nDodds 1975
\nDlouh\u00fd, Duda, Mina\u0159\u00edk 1979<\/td>\n		2,53 \u00b1 0,139 kPa (19,0 \u00b1 1,6 mm Hg)
\n3,25 \u00b1 1,28 kPa (24,3 \u00b1 9,5 mm Hg)
\n2,8 \u00b1 0,9 kPa (21,0 \u00b1 6,9 mm Hg)<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

.<\/span><\/p>\n

5.4.2.2 Svalov\u00fd pl\u00e1\u0161\u0165 termin\u00e1ln\u00edho j\u00edcnu<\/h5>\n
\"Obr.<\/a>

Obr. 6
A. Sch\u00e9ma apol\u00e1rn\u00edho spir\u00e1ln\u00edho syst\u00e9mu svalov\u00fdch vl\u00e1ken j\u00edcnu u \u010dlov\u011bka. Vl\u00e1kna prob\u00edhaj\u00ed p\u0159ev\u00e1\u017en\u011b kraniokaud\u00e1ln\u011b, zat\u00e1\u010dej\u00ed se a k\u0159\u00ed\u017e\u00ed ve sm\u011bru a proti sm\u011bru hodinov\u00fdch ru\u010di\u010dek.
B. Pr\u016fb\u011bh jednotliv\u00fdch svalov\u00fdch snopc\u016f, kter\u00e9 za\u010d\u00ednaj\u00ed v zevn\u00ed vrstv\u011b longitudin\u00e1ln\u00edm pr\u016fb\u011bhem a \u0161roubovit\u011b se zat\u00e1\u010dej\u00ed dovnit\u0159. Na kaud\u00e1ln\u00edm konci j\u00edcnu v m\u00edst\u011b uzav\u00edraj\u00edc\u00edho segmentu je jejich pr\u016fb\u011bh bl\u00edzk\u00fd horizont\u00e1le.
C. Modelov\u00e1 situace odpov\u00eddaj\u00edc\u00ed ta\u017en\u00e9mu uz\u00e1v\u011bru
termin\u00e1ln\u00edho j\u00edcnu (\u201eDehnverschluss\u201c): v\u00e1lec se st\u011bnou tvo\u0159enou elastick\u00fdmi vl\u00e1kny, dole siln\u011bj\u0161\u00edmi. Pod\u00e9ln\u00fd tah p\u0159i spir\u00e1ln\u00edm pr\u016fb\u011bhu vl\u00e1ken (vpravo) vede k uz\u00e1v\u011bru lumen v doln\u00ed t\u0159etin\u011b. P\u0159i paraleln\u00edm pr\u016fb\u011bhu vl\u00e1ken (vlevo) je tah bez efektu. P\u0159evzato podle Stelznera a Lierse (2).<\/p><\/div>\n

Svalovina termin\u00e1ln\u00edho j\u00edcnu p\u0159edstavuje anatomick\u00fd podklad DJS, ani\u017e by zde byl vytvo\u0159en anatomicky definovateln\u00fd sv\u011bra\u010d. J\u00edcnov\u00e1 muskulatura p\u0159ech\u00e1z\u00ed plynule na \u017ealudek, kde mimo pod\u00e9lnou a cirkul\u00e1rn\u00ed vrstvu vytv\u00e1\u0159\u00ed tzv. fibrae obliquae, zvan\u00e9 t\u00e9\u017e Helveti\u016fv nebo Willis\u016fv sval (viz obr. 5). V\u011bt\u0161ina t\u011bchto vl\u00e1ken obep\u00edn\u00e1 ve tvaru smy\u010dky incisura cardiaca a napom\u00e1h\u00e1 p\u0159i udr\u017eov\u00e1n\u00ed Hisova \u00fahlu.<\/p>\n

Zaj\u00edmav\u00e1 je koncepce tzv. angiomuskul\u00e1rn\u00edho ta\u017en\u00e9ho uz\u00e1v\u011bru termin\u00e1ln\u00edho j\u00edcnu, kterou na z\u00e1klad\u011b sv\u00fdch studi\u00ed zve\u0159ejnil Stelzner a Lierse [2]. Podle nich je svalovina j\u00edcnu tvo\u0159ena apol\u00e1rn\u00edm syst\u00e9mem spir\u00e1ln\u00edch vl\u00e1ken. Jejich pr\u016fb\u011bh je v termin\u00e1ln\u00edm j\u00edcnu bl\u00edzk\u00fd horizont\u00e1ln\u00ed rovin\u011b, tak\u017ee na izolovan\u00fdch prepar\u00e1tech se snopce jev\u00ed cirkul\u00e1rn\u011b (obr. 6). Syst\u00e9m pracuje jako spir\u00e1la, kter\u00e1 p\u0159i sv\u00e9m pod\u00e9ln\u00e9m nata\u017een\u00ed uzav\u00edr\u00e1 doln\u00ed segment j\u00edcnu. Na uz\u00e1v\u011bru se pod\u00edl\u00ed i n\u00e1pl\u0148 subepiteln\u011b prob\u00edhaj\u00edc\u00edch ven\u00f3zn\u00edch pleten\u00ed. I kdy\u017e se v t\u011bchto svalov\u00fdch struktur\u00e1ch zat\u00edm nepoda\u0159ilo prok\u00e1zat klasicky definovan\u00fd sv\u011bra\u010d, nen\u00ed pochyb o existenci sv\u011bra\u010de funk\u010dn\u00edho s odli\u0161nou reakc\u00ed hormon\u00e1ln\u00ed a nervovou proti okol\u00ed.<\/p>\n

5.4.2.3 Hormon\u00e1ln\u00ed a farmakologick\u00e1 regulace<\/h5>\n

V roce 1969 upozornili poprv\u00e9 brit\u0161t\u00ed [16] a ameri\u010dt\u00ed [17] pracovn\u00edci, \u017ee endogenn\u00ed a exogenn\u00ed gastrin vyvol\u00e1v\u00e1 vzestup tlaku v oblasti DJS. V n\u00e1sleduj\u00edc\u00edch letech byl zkoum\u00e1n i vliv jin\u00fdch hormon\u016f, farmak a r\u016fzn\u00fdch zevn\u00edch vliv\u016f (tab. 2).<\/p>\n

Studie na zv\u00ed\u0159atech potvrdily rovn\u011b\u017e citlivost DJS na gastrin. Uk\u00e1zalo se, \u017ee antis\u00e9rum gastrinu ru\u0161\u00ed trvaj\u00edc\u00ed tonus DJS u va\u010dice. V\u0161echny tyto poznatky vedly k z\u00e1v\u011bru, \u017ee gastrin je hlavn\u00edm determinantem tonusu DJS. Z toho bylo vyvozeno, \u017ee zmen\u0161en\u00e9 uvol\u0148ov\u00e1n\u00ed endogenn\u00edho gastrinu nebo necitlivost DJS na gastrin je p\u0159\u00ed\u010dinou sn\u00ed\u017een\u00ed intralumin\u00e1ln\u00edho tlaku v t\u00e9to oblasti u gastroezofage\u00e1ln\u00edho refluxu. S t\u00edm souvis\u00ed l\u00e1kav\u00e1 p\u0159edstava mo\u017en\u00e9ho terapeutick\u00e9ho ovlivn\u011bn\u00ed. Tato \u201eteorie gastrinu\u201c v\u0161ak byla bohu\u017eel dal\u0161\u00edmi v\u00fdzkumy ot\u0159esena. P\u0159edev\u0161\u00edm p\u0159\u00edm\u00e1 m\u011b\u0159en\u00ed hladiny gastrinu u nemocn\u00fdch s gastroezofage\u00e1ln\u00edm refluxem a kontroln\u00edch skupin neuk\u00e1zala rozd\u00edly [18]. Dosud z\u016fst\u00e1v\u00e1 otev\u0159en\u00e1 i ot\u00e1zka p\u0159\u00edm\u00e9ho \u010di vagem zprost\u0159edkovan\u00e9ho p\u016fsoben\u00ed gastrinu na DJS.<\/p>\n\n\n\n\n\n\n
Tab. 2<\/span>
\n P\u016fsoben\u00ed r\u016fzn\u00fdch l\u00e1tek na intralumin\u00e1ln\u00ed tlak v oblasti DJS<\/span>
\n(sestaveno podle Jenneweina, Waldecka a dal\u0161\u00edch autor\u016f [1])<\/span><\/td>\n<\/tr>\n
Ovlivn\u011bn\u00ed klidov\u00e9ho tlaku DJS<\/strong><\/td>\n<\/tr>\n
Vzestup<\/strong><\/td>\nPokles<\/strong><\/td>\n<\/tr>\n
gastrin
\npentagastrin
\nparathormon
\nhistamin
\nkalcium
\nkatecholamin
\nparasympatikomimetika
\nalfa adrenergika
\nbeta adrenolytika
\nprostaglandin F2
\nmetoclopramid (paspertin)
\nanacida
\nb\u00edlkovinn\u00e1 strava<\/td>\n		sekretin
\nglukagon
\ncaerulein
\ncholecystokinin (CCK)
\nCCK \u2013 octapeptid
\nmotilin
\nparasympatikolytika
\nalfa adrenolytika
\nbeta adrenoergika
\nprostaglandin E1
\nnarkotika (barbiturany)
\nnikotin, alkohol, kofein
\ntuky<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

.<\/span><\/p>\n

5.4.2.4 Nervov\u00e1 regulace<\/h5>\n

Inervace termin\u00e1ln\u00edho j\u00edcnu je z obou v\u011btv\u00ed nn. vagi a z hrudn\u00ed \u010d\u00e1sti sympatiku. Vl\u00e1kna se v\u011btv\u00ed na povrchu j\u00edcnu a mimo to vytv\u00e1\u0159ej\u00ed pleten\u011b v submuk\u00f3ze \u2013 plexus submucosus Meissneri \u2013 a mezi svalov\u00fdmi vrstvami \u2013 plexus myentericus Auerbachi. \u0158\u00edzen\u00ed motility DJS nen\u00ed jen interakc\u00ed cholinergn\u00edho (parasympatick\u00e9ho) a adrenergn\u00edho (sympatick\u00e9ho) syst\u00e9mu, ale na regulaci se pod\u00edl\u00ed i tzv. purinergn\u00ed nervov\u00fd syst\u00e9m. Jak uk\u00e1zaly \u010detn\u00e9 studie, jeho efekt nen\u00ed zprost\u0159edkov\u00e1n vag\u00e1ln\u00ed a sympatickou inervac\u00ed a rovn\u011b\u017e medi\u00e1tor p\u0159enosu je nejist\u00fd. Snad jde o adenosintrifosf\u00e1t nebo jin\u00e9 puriny, podle nich\u017e vzniklo pojmenov\u00e1n\u00ed [19].<\/p>\n

Podle p\u0159evl\u00e1daj\u00edc\u00edch n\u00e1zor\u016f je tonus DJS udr\u017eov\u00e1n hlavn\u011b vag\u00e1ln\u00ed cholinergn\u00ed iner vac\u00ed, kde\u017eto relaxace je zaji\u0161t\u011bna noncholinergn\u00edm, nonadrenergn\u00edm purinergn\u00edm syst\u00e9mem. Vliv sympatiku je patrn\u011b zanedbateln\u00fd [20]. P\u0159edpokl\u00e1d\u00e1 se, \u017ee autonomn\u00ed reflexy maj\u00ed vysv\u011btlit zm\u011bny tlaku DJS spojen\u00e9 se \u017ealude\u010dn\u00ed kontrakc\u00ed a zv\u00fd\u0161en\u00edm nitrob\u0159i\u0161n\u00edho tlaku. Intramur\u00e1ln\u00ed nervov\u00e9 pleten\u011b jsou schopny udr\u017eet klidov\u00fd tonus, zajistit relaxaci p\u0159i polyk\u00e1n\u00ed a reakci DJS na zv\u00fd\u0161en\u00ed intraabdomin\u00e1ln\u00edho tlaku i p\u0159i p\u0159eru\u0161en\u00ed zevn\u00ed inervace.<\/p>\n

5.4.3 Ostatn\u00ed faktory pod\u00edlej\u00edc\u00ed se na antirefluxn\u00edm mechanizmu<\/h4>\n

Abdomin\u00e1ln\u00ed j\u00edcen za\u010d\u00edn\u00e1 topograficky ve v\u00fd\u0161i br\u00e1ni\u010dn\u00edho hi\u00e1tu a je dlouh\u00fd 10\u201320 mm (obr. 1). Jeho \u0161ikm\u00e9 vy\u00fast\u011bn\u00ed do \u017ealudku spolu s klenut\u00fdm fundem vytv\u00e1\u0159\u00ed hlubok\u00fd z\u00e1\u0159ez \u2013 incisura cardiaca \u2013 zvan\u00fd His\u016fv \u00fahel. Intralumin\u00e1ln\u011b z\u00e1\u0159ezu odpov\u00edd\u00e1 Gubaroffova \u0159asa. Na vytvo\u0159en\u00ed Hisova \u00fahlu se pod\u00edl\u00ed Helveti\u016fv-Willis\u016fv sval.<\/p>\n

Mechanick\u00fdm stla\u010den\u00edm abdomin\u00e1ln\u00edho ezofagu nitrob\u0159i\u0161n\u00edm tlakem se podpo\u0159\u00ed funkce DJS [21] (obr. 5). Tato teorie tzv. kolabovateln\u00e9ho j\u00edcnu vysv\u011btluje podle Borsta a Earlama i mo\u017enost p\u016fsoben\u00ed nitrob\u0159i\u0161n\u00edho tlaku p\u0159i fundoplikaci konstruovan\u00e9 nad br\u00e1nic\u00ed. Rovn\u011b\u017e hypot\u00e9za, \u017ee termin\u00e1ln\u00ed j\u00edcen funguje jako tzv. \u201eflutter valve\u201c (kmitaj\u00edc\u00ed chlope\u0148), se zakl\u00e1d\u00e1 na p\u0159edpokladu, \u017ee j\u00edcen kolabuje p\u0159i p\u0159echodu z negativn\u00edho intratorak\u00e1ln\u00edho tlaku do pozitivn\u00edho intraabdomin\u00e1ln\u00edho tlaku.<\/p>\n

V\u00fdznam Hisova \u00fahlu vysv\u011btluje teorie ventilovan\u00e9ho uz\u00e1v\u011bru kardie, kter\u00e9 v\u011bnoval p\u0159edev\u0161\u00edm z hlediska praktick\u00e9ho chirurgick\u00e9ho vyu\u017eit\u00ed velkou pozornost Rossetti [22]. Podstata t\u00e9to teorie spo\u010d\u00edv\u00e1 v tom, \u017ee intraabdomin\u00e1ln\u00ed, a t\u00edm i intragastrick\u00fd tlak se p\u0159en\u00e1\u0161\u00ed na Gubaroffovu \u0159asu a na intraabdomin\u00e1ln\u00ed j\u00edcen a vytv\u00e1\u0159\u00ed z\u00e1klopkovit\u00fd uz\u00e1v\u011br GES.<\/p>\n

Ezofagogastrick\u00e9 spojen\u00ed je m\u00edstem p\u0159echodu j\u00edcnov\u00e9ho dla\u017edicov\u00e9ho epitelu v cylindrick\u00fd \u017ealude\u010dn\u00ed. Mezi oba typy je vsunuta z\u00f3na tzv. junk\u010dn\u00edho jednovrstevn\u00e9ho cylindrick\u00e9ho epitelu, kter\u00e9mu se p\u0159i\u010d\u00edt\u00e1 v\u00fdznam p\u0159i ochran\u011b sliznice j\u00edcnu p\u0159ed peptick\u00fdm \u00fa\u010dinkem \u017ealude\u010dn\u00ed \u0161\u0165\u00e1vy [23, 24]. Slizni\u010dn\u00ed \u0159asy jsou zde prov\u011b\u0161eny do lumina a vytv\u00e1\u0159ej\u00ed obraz slizni\u010dn\u00ed rozety, kter\u00e9 b\u00fdv\u00e1 p\u0159ipisov\u00e1n v\u00fdznam z\u00e1tky ut\u011bs\u0148uj\u00edc\u00ed vstup do \u017ealudku. O Stelznerov\u011b angiomuskul\u00e1rn\u00edm ta\u017en\u00e9m uz\u00e1v\u011bru termin\u00e1ln\u00edho j\u00edcnu byla ji\u017e zm\u00ednka.<\/p>\n

Na udr\u017een\u00ed zvykl\u00e9 polohy a tvaru GES se pod\u00edlej\u00ed n\u00e1sleduj\u00edc\u00ed struktury (obr. 5):<\/p>\n

    \n
  1. retroperitone\u00e1ln\u00ed fixace zadn\u00ed st\u011bny GES,<\/li>\n
  2. frenoezofage\u00e1ln\u00ed Laimerova membr\u00e1na, zprost\u0159edkuj\u00edc\u00ed vztah j\u00edcnu k ezofage\u00e1ln\u00edmu hi\u00e1tu,<\/li>\n
  3. ligamentum gastrophrenicum,<\/li>\n
  4. ligamentum gastrolienale,<\/li>\n
  5. ligamentum gastrohepaticum,<\/li>\n
  6. arteria gastrica sinistra.<\/li>\n<\/ol>\n

    N\u011bkter\u00e9 slo\u017eky tohoto fixa\u010dn\u00edho apar\u00e1tu byly pro udr\u017een\u00ed kompetence GES zvl\u00e1\u0161t\u011b zd\u016fraz\u0148ov\u00e1ny.<\/p>\n

    Frenoezofage\u00e1ln\u00ed membr\u00e1na p\u0159edstavuje anatomick\u00e9 a funk\u010dn\u00ed spojen\u00ed j\u00edcnu s hi\u00e1tem ezofage\u00e1ln\u00edm a br\u00e1nic\u00ed. Je pokra\u010dov\u00e1n\u00edm horn\u00ed a doln\u00ed br\u00e1ni\u010dn\u00ed fascie, p\u0159i\u010dem\u017e doln\u00ed fascie je hlavn\u00edm elementem. Na j\u00edcen p\u0159ech\u00e1z\u00ed ve dvou listech, kter\u00e9 se jako krani\u00e1ln\u00ed a kaud\u00e1ln\u00ed ram\u00e9nko p\u0159ikl\u00e1daj\u00ed ke st\u011bn\u011b j\u00edcnu, do kter\u00e9 jsou pevn\u011b zakotveny. Horn\u00ed ram\u00e9nko se up\u00edn\u00e1 nad krani\u00e1ln\u00ed okraj DJS. Membr\u00e1na je pevn\u011b zakotvena i ve struktur\u00e1ch br\u00e1nice, zat\u00edmco proti okraj\u016fm hi\u00e1tu je voln\u011b pohybliv\u00e1. To spolu s jej\u00ed elasticitou umo\u017e\u0148uje pom\u011brn\u011b voln\u00fd kraniokaud\u00e1ln\u00ed pohyb j\u00edcnu v rozsahu n\u011bkolika centimetr\u016f [25]. Eli\u0161ka upozor\u0148uje [26] na charakteristick\u00e9 zm\u011bny frenoezofage\u00e1ln\u00ed membr\u00e1ny ve vy\u0161\u0161\u00edm v\u011bku, kter\u00e9 se bl\u00ed\u017e\u00ed n\u00e1lez\u016fm u skluzn\u00e9 hi\u00e1tov\u00e9 hernie. Podle Dillarda a Bombecka m\u00e1 lokalizace \u00faponu frenoezofage\u00e1ln\u00ed membr\u00e1ny vliv na funkci gastroezofage\u00e1ln\u00edho spojen\u00ed [27].<\/p>\n

    Byl zkoum\u00e1n vliv ezofage\u00e1ln\u00edho hi\u00e1tu na funkci GES [28, 29]. Zn\u00e1ma je Jacksonova teorie br\u00e1ni\u010dn\u00edho pinchocku, kter\u00e1 p\u0159edpokl\u00e1d\u00e1 sev\u0159en\u00ed j\u00edcnu kontrakc\u00ed br\u00e1ni\u010dn\u00edch pil\u00ed\u0159\u016f v obdob\u00ed mimo polyk\u00e1n\u00ed. Allison [30] p\u0159edpokl\u00e1dal, \u017ee prav\u00e9 br\u00e1ni\u010dn\u00ed crus svou kontrakc\u00ed p\u0159i inspiriu uzav\u00edr\u00e1 kardii.<\/p>\n

    \u0160etka zd\u016fraz\u0148uje v\u00fdznam koordinace motility cel\u00e9ho gastrointestin\u00e1ln\u00edho traktu [8]. D\u016fle\u017eit\u00e9 je dobr\u00e9 vyprazd\u0148ov\u00e1n\u00ed \u017ealudku a v patogenezi refluxn\u00ed nemoci m\u00e1 v\u00fdznam i duodenogastrick\u00fd reflux. Selye v roce 1938 podvazem pyloru u experiment\u00e1ln\u00edch zv\u00ed\u0159at dos\u00e1hl vzniku hemoragick\u00e9 refluxn\u00ed ezofagitidy [31]. Dob\u0159e je rovn\u011b\u017e zn\u00e1m v\u00fdznam peristaltiky j\u00edcnu pro jeho samo\u010distic\u00ed schopnost.<\/p>\n

    5.5 Kritick\u00e9 zhodnocen\u00ed jednotliv\u00fdch komponent antirefluxn\u00edho mechanizmu<\/h3>\n

    Atkinson [32] v roce 1962 shrnuje d\u016fle\u017eit\u00e9 poznatky o v\u00fdznamu ezofage\u00e1ln\u00edho hi\u00e1tu. Ke gastroezofage\u00e1ln\u00edmu refluxu nedoch\u00e1z\u00ed po prot\u011bt\u00ed hi\u00e1tu nebo par\u00e9ze br\u00e1nice a z\u00f3na zv\u00fd\u0161en\u00e9ho tlaku v termin\u00e1ln\u00edm j\u00edcnu, kter\u00fd je mimo dosah br\u00e1nice, je prokazateln\u00e1 i u skluzn\u00fdch hi\u00e1tov\u00fdch herni\u00ed. Rovn\u011b\u017e rentgenologick\u00e1 pozorov\u00e1n\u00ed sv\u011bd\u010d\u00ed proti \u00fa\u010dasti hi\u00e1tu na z\u00e1bran\u011b gastroezofage\u00e1ln\u00edho refluxu [6]. Muk\u00f3zn\u00ed rozeta nem\u00e1 pro uz\u00e1v\u011br GES z\u00e1sadn\u011bj\u0161\u00ed v\u00fdznam. Pokud se na z\u00e1bran\u011b refluxu pod\u00edl\u00ed sliznice, je to sp\u00ed\u0161e v\u00fdznamem z\u00f3ny junk\u010dn\u00edho epitelu. Je zn\u00e1m\u00e9, \u017ee u skluzn\u00e9 hi\u00e1tov\u00e9 hernie, u n\u00ed\u017e je abdomin\u00e1ln\u00ed j\u00edcen dislokov\u00e1n do hrudn\u00edku a His\u016fv \u00fahel zpravidla vymizel, nemus\u00ed b\u00fdt inkompetence GES. K redukci Hisova \u00fahlu a poru\u0161en\u00ed fixa\u010dn\u00edho apar\u00e1tu GES doch\u00e1z\u00ed po resekci \u017ealudku. S gastroezofage\u00e1ln\u00edm refluxem se zde m\u016f\u017eeme setkat, ale rozhodn\u011b to nen\u00ed pravidlem [33]. Po\u0161kozen\u00ed fixa\u010dn\u00edho apar\u00e1tu GES, v\u010detn\u011b Laimerovy membr\u00e1ny, m\u016f\u017ee v\u00e9st ke vzniku skluzn\u00e9 hi\u00e1tov\u00e9 hernie, co\u017e v\u0161ak nen\u00ed synonymem refluxu. Na druh\u00e9 stran\u011b experiment\u00e1ln\u00ed [34, 35] a klinick\u00e9[9, 36, 37] zku\u0161enosti prokazuj\u00ed, \u017ee rekonstrukce abdomin\u00e1ln\u00edho j\u00edcnu a Hisova \u00fahlu vede k z\u00e1bran\u011b refluxu.Nejd\u016fle\u017eit\u011bj\u0161\u00ed slo\u017ekou antirefluxn\u00edho mechanizmu je DJS, kter\u00fd je schopn\u00fd zesilovat svou funkci p\u0159i zv\u00fd\u0161en\u00ed nitrob\u0159i\u0161n\u00edho tlaku bez ohledu na svou lokalizaci nad br\u00e1nic\u00ed \u010di pod n\u00ed, jak prok\u00e1zali Cohen a Haris [38]. Zji\u0161t\u011bn\u00ed t\u00e9to nez\u00e1vislosti na ostatn\u00edch mechanick\u00fdch faktorech vedlo k n\u00e1zoru, \u017ee tonus DJS je prim\u00e1rn\u00ed, nebo dokonce jedinou z\u00e1branou refluxu.<\/p>\n

    Dodds [39] upozor\u0148uje na dv\u011b skute\u010dnosti, kter\u00e9 by mohly objasnit n\u011bkter\u00e9 rozpory v z\u00edskan\u00fdch v\u00fdsledc\u00edch:<\/p>\n

      \n
    1. V\u011bt\u0161ina experiment\u00e1ln\u00edch d\u016fkaz\u016f byla z\u00edsk\u00e1na pokusy na psech. Ti v\u0161ak nejsou pravd\u011bpodobn\u011b vhodn\u00fdm zv\u00ed\u0159ec\u00edm modelem pro aplikaci z\u00e1v\u011br\u016f na \u010dlov\u011bka. Rozd\u00edln\u00e1 je skladba svaloviny j\u00edcnu, kter\u00e1 je u psa tvo\u0159ena p\u0159ev\u00e1\u017en\u011b pruhovan\u00fdm svalstvem, a rozd\u00edly jsou i ve stavb\u011b frenoezofage\u00e1ln\u00ed membr\u00e1ny. Za vhodn\u011bj\u0161\u00ed zv\u00ed\u0159e pova\u017euje Dodds opici.<\/li>\n
    2. Nen\u00ed jist\u00e9, zdali je p\u0159i lokalizaci DJS nad br\u00e1nic\u00ed skute\u010dn\u011b vylou\u010dena ve\u0161ker\u00e1 spolu\u00fa\u010dast mechanick\u00fdch antirefluxn\u00edch faktor\u016f (muk\u00f3zn\u00ed ucp\u00e1vka, fibrae obliquae, His\u016fv \u00fahel u v\u011bt\u0161\u00edch herni\u00ed), jak se v \u00favah\u00e1ch v\u011bt\u0161inou p\u0159edpokl\u00e1d\u00e1.<\/li>\n<\/ol>\n

      O tom, \u017ee se na \u010dinnosti DJS pod\u00edlej\u00ed dal\u0161\u00ed extrasfinkterick\u00e9, pravd\u011bpodobn\u011b mechanick\u00e9 faktory, sv\u011bd\u010d\u00ed n\u00e1sleduj\u00edc\u00ed pozorov\u00e1n\u00ed:<\/p>\n

        \n
      • Byla zji\u0161t\u011bna radi\u00e1ln\u00ed asymetrie tlaku DJS. V z\u00e1vislosti na orientaci otvor\u016f infuzn\u00edho m\u011b\u0159ic\u00edho kat\u00e9tru byly registrov\u00e1ny nejvy\u0161\u0161\u00ed tlakov\u00e9 hodnoty v lev\u00e9m posterolater\u00e1ln\u00edm kvadrantu sv\u011bra\u010de.<\/span><\/li>\n
      • Zv\u00fd\u0161en\u00ed tlaku bylo nam\u011b\u0159eno i v poloze vy\u0161et\u0159ovan\u00e9ho na boku ve srovn\u00e1n\u00ed s polohou na z\u00e1dech.<\/span><\/li>\n
      • M\u00edrn\u00fd vzestup intralumin\u00e1ln\u00edho tlaku na \u00farovni hi\u00e1tu byl pozorov\u00e1n p\u0159i herniaci<\/span> DJS do hrudn\u00edku.<\/li>\n
      • P\u0159i sn\u00ed\u017een\u00ed tlaku DJS atropinem nedoch\u00e1z\u00ed obvykle ke zv\u00fd\u0161en\u00ed v\u00fdskytu refluxu<\/span> [40].<\/li>\n
      • A\u010dkoliv b\u011bhem polyk\u00e1n\u00ed doch\u00e1z\u00ed ke kompletn\u00ed relaxaci DJS, bylo zji\u0161t\u011bno fluo<\/span>roskopick\u00fdm vy\u0161et\u0159en\u00edm u dobrovoln\u00edk\u016f, \u017ee p\u0159i poloze hlavou dol\u016f nedoch\u00e1zelo p\u0159i polyk\u00e1n\u00ed na sucho k refluxu do j\u00edcnu. Doddsova pracovn\u00ed skupina rovn\u011b\u017e prok\u00e1zala, \u017ee relaxace sv\u011bra\u010de nen\u00ed ekvivalentn\u00ed s jeho otev\u0159en\u00edm.<\/li>\n<\/ul>\n

        Dal\u0161\u00ed zaj\u00edmav\u00e9 poznatky poskytuj\u00ed vy\u0161et\u0159en\u00ed pacient\u016f s prokazateln\u00fdm refluxem do j\u00edcnu:<\/p>\n

          \n
        1. A\u010dkoliv pr\u016fm\u011brn\u00e9 hodnoty tlaku DJS u nemocn\u00fdch s GER jsou ni\u017e\u0161\u00ed ne\u017e u kontroln\u00ed asymptomatick\u00e9 skupiny [60, 346], mohou se u jednotlivc\u016f vyskytovat hodnoty opa\u010dn\u00e9.<\/li>\n
        2. Je zaj\u00edmav\u00e9, \u017ee u n\u011bkter\u00fdch nemocn\u00fdch p\u0159es farmakologick\u00e9 zna\u010dn\u00e9 zv\u00fd\u0161en\u00ed tlaku DJS na 4,0 kPa (30 mm Hg i v\u00edce) p\u0159etrv\u00e1v\u00e1 GER, stejn\u011b jako u n\u011bkter\u00fdch operovan\u00fdch p\u0159es vymizen\u00ed GER nedojde k v\u00fdrazn\u00e9mu zv\u00fd\u0161en\u00ed tlaku DJS [41].<\/li>\n<\/ol>\n

          Ve druh\u00e9 polovin\u011b minul\u00e9ho stolet\u00ed, kdy byla v\u00fdzkumu funkce GES v\u011bnov\u00e1na velk\u00e1 pozornost, m\u016f\u017eeme sledovat t\u0159i obdob\u00ed naz\u00edr\u00e1n\u00ed na podstatu antirefluxn\u00edho mechanizmu GES. V prvn\u00edm je shled\u00e1v\u00e1na odpov\u011b\u010f v cel\u00e9 \u0159ad\u011b mechanicky koncipovan\u00fdch hypot\u00e9z. Ve druh\u00e9m obdob\u00ed je pova\u017eov\u00e1n doln\u00ed j\u00edcnov\u00fd sv\u011bra\u010d za jedin\u00fd faktor zodpov\u011bdn\u00fd za kompetenci GES. Kone\u010dn\u011b posledn\u00ed desetilet\u00ed p\u0159in\u00e1\u0161ej\u00ed st\u0159\u00edzliv\u00fd pohled respektuj\u00edc\u00ed hlavn\u00ed roli DJS, ale praktick\u00e9 zku\u0161enosti dolo\u017een\u00e9 experiment\u00e1ln\u00edmi pracemi ukazuj\u00ed, \u017ee ani v\u00fdznam ostatn\u00edch komponent tohoto mechanizmu nelze p\u0159ehl\u00ed\u017eet. Ani sou\u010dasn\u00e9 n\u00e1zory anatom\u016f, kte\u0159\u00ed se zab\u00fdvaj\u00ed problematikou j\u00edcnu, nep\u0159in\u00e1\u0161ej\u00ed v tomto ohledu zm\u011bny proti popsan\u00fdm z\u00e1v\u011br\u016fm (41, 42, 43, 44, 45, 46).<\/p>\n

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            5.1 Anatomick\u00e1 a funk\u010dn\u00ed definice J\u00edcen je svalov\u00e1 trubice spojuj\u00edc\u00ed farynx se \u017ealudkem, kter\u00e1 zaji\u0161\u0165uje transport potravy a sekret\u016f mezi t\u011bmito dv\u011bma org\u00e1ny. V klidu je j\u00edcen pr\u00e1zdn\u00fd a obsah patogenn\u00edch mikrob\u016f je d\u00e1n komunikac\u00ed s dutinou \u00fastn\u00ed a potravou. Ezofagus za\u010d\u00edn\u00e1 ve v\u00fd\u0161i cartilago cricoidea, co\u017e odpov\u00edd\u00e1 6.-7. kr\u010dn\u00edmu obratli. V kr\u010dn\u00edm \u00faseku prob\u00edh\u00e1 […]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":65,"menu_order":30,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":"","_links_to":"","_links_to_target":""},"class_list":["post-241","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/241","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=241"}],"version-history":[{"count":50,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/241\/revisions"}],"predecessor-version":[{"id":3546,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/241\/revisions\/3546"}],"up":[{"embeddable":true,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/65"}],"wp:attachment":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=241"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}