CASE PRESENTATION

234-73-99

Abdul Mannan ChatthaM09021Phase III medical Student

• 55 YR MALE

• PRESENTING COMPLAINT:

• DIFFICULTY SWALLOWING – 1 YEAR

• HEARTBURN – 1-2 YEARS

• HOPC

• THE PATIENT EXPERIENCED DYSPHAGIA WHILE SWALLOWING SOLIDS. IMPROVED WITH DRINKING WATER. FEELING OF FOOD STUCK IN THE THROAT.

• EPIGASTRIC BURNING – INCREASED WITH SPICY AND OILY FOOD.

History

• NO NAUSEA/VOMITING

• NO OTHER SYSTEMIC COMPLAINTS

• ROS

• NO H/O WEIGHT LOSS

• NO CHANGE IN BOWEL HABITS

• NORMAL APPETITE

• SLIGHTLY DISTURBED SLEEP

• PMH

• HISTORY OF ASTHMA IN CHILDHOOD

• PERSONAL HX

• MARRIED (2 CHILDREN), BUSINESSMAN

• NO ADDICTIONS

• FAMILY HX

• MOTHER RECENTLY DIED DUE TO BREAST CA

EXAMINATION

• GPE

• OVERWEIGHT GENTLEMAN BMI 26

• MILD PALLOR

• ABDOMINAL EXAMINATION

• UNREMARKABLE

MANAGEMENT IN CLINIC

• STARTED ON PPIS AND MOTILIUM

• ADVISED FOLLOW UP AFTER 2 WEEKS

AFTER 1 WEEK….

• MILD CHANGE IN SYMPTOMS

• ADVISED BARIUM SWALLOW

HIATAL HERNIA

• PROTRUSION OF THE STOMACH UPWARD INTO THE MEDIASTINAL CAVITY THROUGH THE ESOPHAGEAL HIATUS OF THE DIAPHRAGM

• FOUR TYPES

• TYPE I SLIDING HIATAL HERNIA

• TYPE II PARAESOPHAGEAL HIATAL HERNIA

• TYPE III COMBINED

• TYPE IV LARGE HERNIAS CONTAINING ABDOMINAL VISCERA

PATHOPHYSIOLOGY

• SIZE OF HIATUS NOT FIXED, NARROWS WITH INC. IN INTRA-ABDOMINAL PRESSURE

• PHRENOESOPHAGEAL LIGAMENT IS A FIBROUS LAYER OF CONNECTIVE TISSUE AND MAINTAINS THE LES WITHIN THE ABDOMINAL CAVITY

• A HIATAL HERNIA COMPROMISES REFLUX BARRIER

• REDUCED LES PRESSURE

• REDUCED ESOPHAGEAL ACID CLEARANCE

• LONGER TRANSIENT LES RELAXATION EPISODES PARTICULARLY AT NIGHT TIME

CLINICAL PRESENTATION

• MOSTLY ASYMPTOMATIC

• PREDISPOSE/WORSEN REFLUX

• NO CORRELATION BETWEEN SIZE OF HIATAL HERNIA AND SEVERITY OF SYMPTOMS.

• BURNING EPIGASTRIC/SUBSTERNAL PAIN OR TIGHTNESS

• MAY BE DESCRIBED AS TIGHTNESS IN CHEST

• INCREASES WITH ALCOHOL, CAFFEINE, TOBACCO

ESOPHAGEAL COMPLICATIONS

• INTERMITTENT BLEEDING DUE TO ESOPHAGITIS

• CAMERON ULCERS

• IRON DEFF. ANEMIA

NONESOPHAGEAL COMPLICATIONS

• INCARCERATION

• SUDDEN ONSET OF VOMITING AND PAIN

• REQUIRES IMMEDIATE OPERATIVE INTERVENTION

PREDISPOSING FACTORS

• AGE

• WOMEN > MEN

• FIBER-DEPLETED DIET

• OBESITY

• ABDOMINAL ASCITES

• CHRONIC ESOPHAGITIS

• WHICH COMES FIRST??

TYPE I

• > 90%

• WOMEN > MEN (4:1)

• ESOPHAGOGASTRIC JUNCTION LIES ABOVE THE DIAPHRAM

• USUALLY REDUCIBLE

TYPE II

• 3-5%

• GEJ IN NORMAL INTRAABDOMINAL POSITION

• FUNDUS MIGRATES SUPERIORLY ALONGSIDE GEJ AND ESOPHAGUS AND INTO THE MEDIASTINUM

• GENERALLY ASYMPTOMATIC UNTIL THEY INCARCERATE OR BECOME ISCHEMIC

• DYSPHAGIA, BLEEDING, AND OCCASIONAL RESP. DISTRESS

TYPE III

• MORE COMMON THAN TRUE TYPE II HERNIA

• ENLARGEMENT OF DEFECT IN TYPE I

OR• STRECHING OF PHRENOESOPHAGEAL LIGAMENT OVER TIME

IN A TYPE II HERNIA

DIAGNOSIS

• USUALLY SUSPECTED BASED ON HX

• CHEST X RAY

• AIR FLUID LEVEL BEHIND THE HEART AND OFTEN ONE BEHIND DIAPHRAGM

• BARIUM SWALLOW

• EVAULATE DYSPHAGIA

• BARIUM SWALLOW

• UPPER GI ENDOSCOPY

• SEE PATHOLOGY (ESOPHAGITIS, BARRETT’S)

• BIOPSY

• MANOMETERY

• ESOPHAGEAL MOTILITY, LES FUNCTION, LES POSITION

• LOW SENSITIVITY COMPARED TO ENDOSCOPY

TREATMENT

• LIFESTYLE CHANGES

• AVOID MEALS AT LEAST 3 HOURS PRIOR TO SLEEPING

• ELEVATE HEAD WHILE SLEEPING

• WEIGHT REDUCTION

About one-third of patients fail to respond to initial medical treatment, and half of those who initially respond will ultimately relapse and require surgery.

• MEDICAL THERAPY

• AVOID GASTRIC STIMULANTS

• ANTACIDS

• H2 BLOCKERS AND PPIS

• PROKINETIC AGENTS (METOCLOPRAMIDE)

INDICATIONS FOR SURGERY

• FAILURE OF MEDICATIONS

• NONCOMPLIANCE WITH MEDICAL TREATMENT

• PREFERENCE FOR SURGERY OVER LIFELONG MEDICATIONS (COST, INCONVENIENCE, SIDE EFFECTS)

• SEVERELY INCOMPETENT LES

• PARAESOPHAGEAL HERNIA

SURGERY

• RETURN HERNIA CONTENT BELOW DIAPHRAGM

• CORRECT HERNIA DEFECT

• PREVENT REFLUX OF GASTRIC ACID INTO THE LES BY RECONSTRUCTION OF A VALVE MECHANISM

• HERNIA CONTENTS REDUCED

• CRURAL REPAIR

• OPTIONAL MESH REINFORCEMENT

• NARROW HIATUS TO APPROX 2.5CM DIAMETER

• FUNDOPLICATION

• FUNDUS WRAPPED AROUND LOWER END OF ESOPHAGUS

• NISSEN - 360 DEGREES

• MIRROR IMAGE OF ANT. AND POST. FUNDUS

• MEET AT 9 O’CLOCK POSITION

• NISSEN-ROSSETTI – ANTERIOR WALL USED ALONE

COMPLICATIONS

• INTRAABDOMINAL INFECTION

• ESOPHAGEAL PERFORATION

• DYSPHAGIA

• DISRUPTION OF REPAIR WITH RECURRENT SYMPTOMS

• VOMITING IS NOT POSSIBLE

• BELCHING DIFFICULTY

• BLOATING (GAS BLOAT SYNDROME)

• SELF LIMITING WITHIN 2-4 WKS, BUT MAY PERSIST

OUTCOME OF LAPROSCOPIC FUNDOPLICATION

• SYMPTOMATIC

• 90% PATIENTS SYMPTOM FREE AFTER 10 YRS

• 92% HAVE RESOLUTION OF ANEMIA

• ANATOMIC

• 5-10% MAY REQUIRE REDO PROCEDURES

RESEARCH ARTICLE: LAPAROSCOPIC MESH-AUGMENTED HIATOPLASTY WITHOUT FUNDOPLICATION AS A METHOD TO TREAT LARGE HIATAL HERNIAS

• RETROSPECTIVE STUDY.

• COMPARED LAPAROSCOPIC HIATAL HERNIA REPAIR WITH FUNDOPLICATION TO LAPAROSCOPIC MESH AUGMENTED HIATOPLASTY WITHOUT FUNDOPLICATION.

• 55 PATIENTS, FOLLOWED FOR 72 MONTHS.

• GAS BLOATING DECREASED FROM 1.5 TO 0.5.

• DYSPHAGIA BEFORE SURGERY VALUE 0.7, AFTER SURGERY 0.6.

• 96% COULD BELCH, 92% COULD VOMIT.

• MESH RELATED STENOSIS OCCURRED IN 2%.

• LMAH IS FEASIBLE, SAFE AND PROVIDES AN ANTI-REFLUX EFFECT, EVEN WITHOUT FUNDOPLICATION.

BACK TO OUR PATIENT…..

• REFERRED TO GASTROENTEROLOGIST

• LOST TO FOLLOW UP :(

REFERENCES

• BAILEY AND LOVE’S SHORT PRACTICE OF SURGERY.

• HTTP://LINK.SPRINGER.COM/ARTICLE/10.1007/S00595-013-0609-2/FULLTEXT.HTML

• DOWNSTATESURGERY.ORG

• EMEDICINE.COM

• AJR AM J ROENTGENOL. 2003 AUG;181(2):403-14. INTRATHORACIC STOMACH REVISITED. ABBARA S, KALAN MM, LEWICKI AM.DEPARTMENT OF RADIOLOGY, GEORGETOWN UNIVERSITY MEDICAL CENTER, 3800 RESERVOIR RD., N.W., WASHINGTON, DC 20007, USA.

• POLOMSKY M, PETERS JH, SCHWARTZ SI. HIATAL HERNIA AND DISORDERS OF THE SPINE: A HISTORICAL PERSPECTIVE. DIS ESOPHAGUS. OCT 25 2011

• SALVADOR R, DUBECZ A, POLOMSKY M, GELLERSON O, JONES CE, RAYMOND DP, ET AL. A NEW ERA IN ESOPHAGEAL DIAGNOSTICS: THE IMAGE-BASED PARADIGM OF HIGH-RESOLUTION MANOMETRY. J AM COLL SURG. JUN 2009;208(6):1035-44.

• MINJAREZ, RC; JOBE BA. "SURGICAL THERAPY FOR GASTROESOPHAGEAL REFLUX DISEASE". GI MOTILITY ONLINE. DOI:10.1038/GIMO56 (INACTIVE 2008-06-21).

THANK YOU