Hiatal hernia

Hiatal hernia(열공 탈장)
SMC F1 김남준/이준행
Department of Medicine, Samsung Medical Center,
Sungkyunkwan University School of Medicine, Seoul, Korea
Contents
Definition & Anatomy
Endoscopic diagnosis
Clinical significance
Case review
Definition
 A herniation of part of the stomach into
thoracic cavity through the esophageal hiatus
in the diaphragm
Harrison 17th
Anatomy (Esophageal hiatus &
Phrenoesophageal ligament)
www.laparoscopicexperts.com/images
Anatomy (Normal esophagogastric junction)
Diaphragm
Phrenoesophageal ligament
Ascending limb
Infradiaphragmatic fascia
Descending limb
Squamocolumnar junction
Etiology
• Loss of elasticity of the phrenoesophageal ligament
=>1. Aging ( repetitive stress of swallowing)
2. Excessive contraction of the esophageal
( power athletes, pregnancy, previous surgery etc.)
• Brachy-esophagus (= short esophagus)
- Reflux esophagitis itself
=> Acidification of the esophageal mucosa
=> longitudinal m. contraction
Gut and Liver, Vol. 5, No. 3, September 2011, pp. 267-277
Development of hiatal hernia
 This loss of elasticity might be caused by factors such as
excessive contraction of the longitudinal esophageal muscles,
increased abdominal pressure, genetic predisposition and agerelated degeneration.
• Interestingly, a study in opossums showed
that acid exposition to the esophagus
induces esophageal shortening.
• It is therefore conceivable that acid gastroesophageal reflux itself might induce,
maintain or even increase a sliding hiatus
hernia.
Opossum 북미산 주머니쥐
van Herwaarden. Eur J Gastroenterol Hepatol 2005;16:831-835
Types- Type I ( Sliding hiatal hernia)
Anatomy of sliding histal hernia
Anatomy of hiatal hernia
Hernia sac
Squamocolumnar junction = B-ring
Diaphragmatic orfice
Diaphragmatic orfice
Ampulla
A-ring
B-ring
Hiatal hernia
Hiatal hernia
Schatzki ring
http://www.mindspring.com/~dmmmd2/es_ge_04.html
Types- Type II ( Para-esophageal hernia)
Paraesophageal hernia
gastric folds
hernia sac
diaphragmatic opening
ulcer scar
Types- Type III & IV
Pinchcock action of the right crus
Anterior view
Lateral view
Allison PR. Surg Gynecol Obstet 1951;92:419-431
Axial and ratial pressure topography
Kahrilas. Gut 1999;44:476-482
Diagnosis
 Radiographic assessment
 Endoscopic assessment
 Manometric assessment
Endoscopic assessment
 The proximal dislocation of GEJ of > 2cm above
diaphragmatic indentation (pinkchcock action)
Endoscopic anatomy of EGJ
Esophagus
Esophagogastric junction (EGJ)
= Proximal margin of gastric folds
= Distal end of palisade zone
= Pinchcock action (PCA)
= Squamocolumnar junction
PZ
3 cm
Stomach
Endoscopic view of EGJ
4-6 longitudinal symmetrical folds
Endoscopic view of EGJ
Angle of His
= crescent of the cardia
Gastroesophageal flap valve
- Endoscopic Hill grading system
Hill. Gastrointest Endosc 1996;44:541-547
The diaphragmatic factor
Expiration
Inspiration
Limitation (1)
 Endoscopic definition of GEJ
;
-SCJ
(Columnar-lined esophagus or Barrett’s esophagus)
-Proximal margin of gastric folds
(Sometimes have difficulty identifying this marker clearly)
-Palisade zone
(Not visible in the presence of inflammation )
Columnar-lined esophagus
Why 2 cm for sliding hiatal hernia?
http://www.hosppract.com/issues/1998/11/cemitt.htm
Short segment hiatal hernia
< 2 cm
Pinchcock action (PCA)
Limitation (2)
 Measuring the size of hiatal hernia with incisor
.
 When (during insertion or removal)
Which phase of respiration
How much air should be insufflated
.
 Retching or belching
.
 Inter- and intra-observer variation
Hiatal hernia is closely related to reflux symptoms,
reflux esophagitis
Hiatal hernia is closely related to reflux symptoms,
reflux esophagitis
Gordon C. Aliment Pharmacol Ther 2004;20(7):719-732
Hernia Size Is the Dominant Determinant of
Esophagitis Presence and Severity in GERD
Am J Gastroenterol 2001;96:1711-1717.
Barrett’s esophagus is closely related to hiatal
hernia
Barrett’s esophagus with high-grade dysplasia or
adenocarcinoma is closely related to hiatal hernia
Hiatal hernia의 해석 (1)
 무증상 성인에서 발견되는 경증의 hiatal hernia에는 임상
적 의의를 부여하지 않는다.
 무증상 성인에서 발견되는 심한 hiatal hernia는 환자에게
식도증상 여부를 물어보라는 sign 정도로 간주한다.
Endotoday
Hiatal hernia의 해석 (2)
 위식도 역류증상이 있는 환자에서 mucosal break를 동반
하지 않은 hiatal hernia는 비록 erosive esophagitis라고
진단할 수 없더라도 GERD의 임상진단을 support하는 간
접적인 소견으로 간주한다
 비특이적 상부위장관 증상이 있는 환자에서 mucosal
break를 동반하지 않은 hiatal hernia는 GERD일 가능성이
있음을 시사하는 소견이다. 즉 GERD에 초점을 맞춘 상세
한 증상평가가 필요하다.
Endotoday
Case(1)- Mixed type hiatal hernia
Case(2)- Hiatal hernia with stenosis
- Schatzki ring
Case(2)- Hiatal hernia with stenosis
- Schatzki ring
Barrett esophagus + hiatal hernia
Case(3)- Cameron ulcers
Gastroenterology 2005;129:7
Reflux esophagitis + hiatal hernia