What Are the Most Common Symptoms of a Paraesophageal Hernia?

Laparoscopy, abdominal wall hernia surgery, People's Hospital of Xinjiang Autonomous Region

Hiatal hernia

The esophagus enters the abdominal cavity from the posterior mediastinum through a hole in the posterior diaphragm. This hole is called a esophageal hiatus. The gastric cardia and abdominal esophagus or abdominal viscera penetrate into the thorax through this hole and its side, which are called hiatalhernias. Hiatal hernia and reflux esophagitis can exist at the same time, or they can exist separately. Recognize and distinguish the two It is very important for clinical work.

Laparoscopy, abdominal wall hernia surgery, People's Hospital of Xinjiang Autonomous Region

Causes of esophageal hiatal hernia

The etiology of esophageal hiatal hernia is still controversial. A small number of patients with juvenile disease have congenital developmental disorders, forming larger esophageal hiatus and weak tissue around the hiatus. In recent years, it is considered that the acquired factor is the main factor. Chronic intra-abdominal pressure is associated. The physiological role of the esophagogastric junction is still unclear. When the function of the esophagogastric junction is sound, it has a valve function. Liquid or solid matter is swallowed into the stomach, but it does not return. It can only return in small amounts when snoring or vomiting. Factors that ensure this normal function are: pinching of the diaphragm to the esophagus; mucosal folds of the esophagus and gastric junction; the esophagus and the bottom of the stomach are anatomically connected at an acute angle; the abdominal esophagus participates in the lower esophagus Valvular effect; the role of the internal sphincter in the physiological high pressure area of the lower esophagus. Most people think that the fifth factor of the above factors is the main factor to prevent reflux, and the nearby normal anatomical relationship supports this. The effect of preventing gastric juice reflux is dominated by the vagus nerve, and this effect disappears after the vagus nerve is removed. When the pressure in the stomach increases, gastric fluid easily flows back into the esophagus. Squamous epithelial cells of the esophageal mucosa have no resistance to gastric acid. Long-term erosion by refluxing acid can cause reflux esophagitis. Those with mild mucosal edema and hyperemia will form superficial ulcers, which are spotted or fused into slices. Mucosa The lower tissue is edema, the mucous membrane is damaged and covered with pseudomembrane, which is easy to bleed. Inflammation can penetrate into the muscle layer and fibrous outer membrane, and even involve the mediastinum, making the tissue thicker, brittle, and increasing nearby lymph nodes. In the later stages of esophageal wall fibrosis, scarring stenosis and shortening of the esophagus. In some cases, it can be found that the esophageal membrane is pulled under the aortic arch, up to the level of the 9th thoracic spine.

The severity of reflux esophagitis can vary depending on the following factors: reflux of gastric juice, acidity of reflux fluid, length of time, and individual resistance. Most of the pathological changes of reflux esophagitis can be recovered. After the esophageal hiatal hernia is corrected, the mucosal lesions may be repaired.

Oesophageal hiatal hernia symptoms

The patient complained of typical symptoms, ^[1] such as heartburn and acid reflux, or atypical symptoms such as foreign body sensation in the throat, hoarseness, hydatid disease, acidic water, chest pain, and paroxysmal cough. The diagnosis of reflux esophagitis should be considered for asthma and aspiration pneumonia and other non-ulcerative dyspepsia symptoms. If antacid treatment can relieve the symptoms, the diagnosis can be roughly confirmed. To confirm the diagnosis, esophagoscopy and 24-hour pH monitoring should be performed.

Endoscopy is the main method to diagnose hiatal hernia. Barium meal tests are most commonly used, but require manual help to show a hernia. With the patient lying on his left side and his head down, when the stomach is filled with barium, he compresses his abdomen with his hands to force the patient to breathe out. At this time, the indication of a hiatal hernia may appear: the subepithelial esophagus (abdomen) becomes shorter and wider Or disappeared, the cardia showed a traction-like upward traction, the gastric sac was visible on the diaphragm, and the esophagogastric stricture ring (Schatzki annular stenosis) appeared on the diaphragm. When there is esophageal stenosis, the mucosa deformes and the lumen narrows. When the esophagus is short, there is a thick gastric mucosa, and the esophageal-gastric junction can be raised to the level of the 9th thoracic vertebra due to scar contraction.

For barium meal examination, Muller's technique is more effective in stimulating reflux (close the glottis after exhaling, and then inhale vigorously to increase the negative pressure in the chest and promote the barium in the stomach to enter the esophagus). Some people use it The "drink" method; let the patient drink water into the stomach, mix it with barium, and squeeze the abdomen. In conditional hospitals, upper gastrographs should be made into videotapes for repeated examinations. Most people believe that X-ray reflux signs may not be present when a hiatal hernia is present, and hiatal hernias may not be present when there are signs of reflux. There is still disagreement on whether a reticular traction is diagnosed as a hiatal hernia. A normal esophageal ampulla should not be mistaken for a hiatal hernia, and diffuse esophageal spasm can occur with hiatal hernias and gastric reflux. Lack of peristaltic function of esophagus during scleroderma and achalasia is also different from hiatal hernia. If mechanical narrowing of the esophagus is found, multiple observations should be made. To distinguish new organisms, ulcerative benign constriction, or esophageal motility disease, it is generally believed that the report of the cause of the constriction by the radiologist can only be used as a reference for diagnosis, and each patient must have a histological diagnosis.

X-ray barium radiography of esophageal hiatal hernia:

Gastric mucosa traction esophageal hiatal hernia X-ray barium radiography: Stomach gastroesophageal hiatal hernia X-ray barium meal radiography: on the diaphragm, Schatzki ring is moved up, endoscopic endoscopy is the second diagnosis of esophageal hiatus Method of inspection. Fiber gastroscopy is safer and less painful than metal rigid endoscopy, and the stomach and duodenum can be examined at the same time to eliminate the factors that cause gastric pressure to increase. It can be used multiple times and is convenient for inspection. If there is a hiatal hernia, the lower esophageal sphincter is relaxed, and it is open when exhaling and inhaling. Under normal circumstances, the esophagogastric junction decreases during inhalation, and if there is a hernia, it does not change position. The level of gastric fluid in esophagoscopy is higher than normal. In the case of reflux esophagitis, the number of erythema, ulcers, attempts and their arrangement can be observed through gastroscope, ulcer bleeding, mucosal erosions and puncture. If the cardia is open after the breathing cycle, this is another indication of reflux. If the patient complains mainly of dysphagia, it is applied to the "T" technique and observing the cardia from below. It may be possible to rule out the presence of early cancer in this area and retract the gastroscope to the esophagus. It is important to check carefully and step by step. If esophageal constriction and severe esophagitis are found, or if Barrett's columnar epithelium is suspected, multiple biopsies should be performed. Malignant changes can also occur in esophageal ulcers. When the cancer cannot be ruled out, a deep biopsy is performed with a hard metal microscope to confirm the diagnosis. For some cases of esophageal constriction, the diagnosis and observation of the effect of dilation can be further confirmed during the first endoscopic examination. If regurgitation is suspected, or a hiatal hernia is found without symptoms of regurgitation and no signs of regurgitation on radiography, esophageal function tests should be considered. When the patient's main complaint is dysphagia, barium meal imaging and endoscopy are better than esophageal function test; when dysphagia is not a major symptom, and barium meal test is double negative, first consider esophageal function test. After clear diagnosis, it may be avoided. Laparoscopy. Esophageal function tests can be completed in the clinic, including esophageal manometry, standard acid reflux tests, pH electrode placement in the esophagus for acid removal tests and acid perfusion tests. For more complicated cases, hospitalization can be performed for 24 hours pH monitoring and continuous pressure measurement to provide more information.

Esophageal manometry:

When the internal pressure of the esophagus is measured in different planes at the same time, it can provide esophageal motion parameters. In recent years, a multi-conductor micro-balloon manometry method has been developed in China, which is simpler, safer, and reusable. The lower esophageal peristalsis amplitude is low during esophagitis, without peristalsis or abnormal peristalsis, and 2.67 kPa (20 mmHg) is high when normal. Too band. Gastric reflux is prone to occur below 1.33kPa (10mmHg). Pressure measurement can identify atypical pain caused by myocardial infarction and biliary disease. Standard acid reflux test: 0.1mol / LHCL 150 300ml is injected into the stomach, and the electrode is slowly pulled. The electrode was placed 5 cm above the high pressure area of the lower esophagus. Measure pH values at 5, 10 and 15 cm. At the same time with Valsala technique (glottic closure and forced exhalation to increase intrathoracic pressure) and Muller technique 9 after exhalation, the sound is closed to inhale vigorously, increase intrathoracic negative pressure and change position, induce gastroesophageal reflux), pH <4 Positive for more than 5min. This test is helpful when the clinical diagnosis of other methods is inaccurate. When correct, the pH value in the stomach is 1 to 4, and the pH value in the esophagus in the high-pressure area is 5 to 7. If the pH electrode is used to measure within 2cm from the stomach to the lower esophagus, and the pH value changes from 2 to 2.4 to 6.5 to 7.0, it means that the cardia function is normal. Acid scavenging test: The pH electrode is still placed 5cm above the high pressure area. 15cmml 0.1mol / LHCL is injected into the middle part of the esophagus through the proximal end of the catheter. The patient is required to swallow every 30s to eliminate the acid in the esophagus. 5 or more swallows required. Normal people are under 10 times. This method does not confirm the presence or absence of gastric fluid reflux, but only indicates the severity of esophagitis. Acid perfusion test: If reflux symptoms are not obvious, this method can be used to check. The catheter is still placed in the middle of the esophagus, with its proximal end behind the patient, and two intravenous fluid bottles connected by a Y-shaped tube. One bottle contains 0.1mol / L HCL solution, and the other contains saline. Each bottle of liquid was perfused for about 10 minutes, and the patient's response to the perfusion was recorded by the observer. Such as the perfusion of acid solution caused the symptoms of spontaneous reflux, but the saline did not respond. A positive acid perfusion test indicates that the patient's symptoms are caused by acid reflux, not by esophageal dyskinesia.

Long-term pH monitoring method:

Patients who have had previous esophageal surgery, combined with other diseases, and those who are suspected of having reflux caused by aspiration pneumonia or suffering from "angina pectoris", can provide valuable diagnostic data for continuous monitoring of 24hpH. After making a series of standard esophageal function tests, the pH electrode was left 5 cm above the high-pressure area of the esophagus in the far section. The electrode was connected to a banner chart instrument and recorded by a pH meter. Record the patient's activities and symptoms within 24 hours. During this time the patient eats normally, but restricts water and food variety to a pH value> 5. The number of reflux episodes can be measured in supine and upright positions, based on the frequency and duration of the episodes. When the pH is higher than 7, it can be set as alkaline reflux. 24h pH monitoring is currently considered to be the most reliable and sensitive method for diagnosing gastroesophageal reflux. Changes in esophageal pH can be recorded continuously for 10, 12, and 24 hours. The detection indicators are: the number of times pH <4 in 24h; the percentage of pH <4 in the total time; the number of times pH <4 exceeds 5min; the longest acid exposure time. These measured values can be compared with normal people to make a diagnosis of gastroesophageal reflux. The latest generation of 24h esophagus pH and pressure is recorded only synchronously. The subject is completely under normal physiological conditions, and has been developed in China. In recent years, ultrasound examination of the esophagus and gastric cardiae, measuring the length of the esophagus and abdominal segment, is more effective for diagnosing smaller hiatal hernias than barium meal X-rays. Examination of the paraesophageal hernia with magnetic resonance can clearly determine the nature of the hernia content.

Esophageal hiatal hernia

Physical examination found: no special.

Auxiliary examination: mainly rely on x-ray examination to confirm the diagnosis, routine chest radiography and chest radiography to pay attention to the back of the heart or on both sides of the heart shadow whether there is air-containing sac cavity and gas-liquid plane, check for barium swallowing hernia And hernia sac appear gastric mucosa shadow, and observe the appearance of epigastric gastric ring on the diaphragm. If one or more of the above signs appear in a barium meal examination, the diagnosis of a sliding hiatal hernia can basically be established. Endoscopy can be used to rule out esophageal ulcers, inflammation, stenosis, and space-occupying lesions, and the dentate line can be seen.

Identification: This type is the most common, accounting for about 90% of all hiatal hernia cases. However, if the diameter of the gastroesophageal hiatus opening is not enlarged slightly, the esophageal membrane elongates and becomes thin, so that the gastric cardia can slide up into the hiatus and then enter the chest cavity. There are no defects or cracks in the intra-abdominal myometrium that covers the holes and extends into the esophagus wall, so there is no real hernia sac. Most cases of this hernia were found during a barium meal examination. The site where the esophageal membrane extends into the submucosa of the esophagus wall is still in the normal position, that is, 3 to 4 cm above the esophagogastric junction (scaly epithelial cells and columnar epithelium). Cell junction), so there are no symptoms of gastroesophageal reflux. A large sliding hiatal hernia can be found during a barium meal examination when the patient is at rest, and a gastric sac> 3 cm has protruded into the chest cavity, often accompanied by insignificant gastroesophageal reflux every hour. It can be found during surgery that the esophagus membrane of these cases extends into the esophagus wall closer to the junction of the gastroesophagus than normal people. It is not clear whether the low penetration is caused by congenital or acquired factors. This hernia is rare, accounting for about 2% of all hiatal hernias, but it has important clinical significance because the abdominal viscera hernia enters the chest cavity. This hernia has a defect in the esophagus, usually left anterior to the fissure, and occasionally posteriorly right. Due to the existence of this defect, the peritoneum can pass through the defect to become a true hernia sac, and the adjacent stomach also hernias into the chest cavity through this fascial defect. Because the esophageal membrane cannot limit the upward moving stomach for a long time, and the thoracic pressure is lower than the abdominal pressure for some time, this defect must be progressively enlarged. In the later stage, the entire stomach can be herniad into the chest cavity, while the cardia is still fixed in place by the esophageal membrane, and the pylorus has approached it. The stomach can rotate, twist, obstruct and narrow, and the chest and stomach expand and rupture. If the diagnosis and treatment are delayed, Any of these complications can lead to death. For these reasons, early surgery should be considered, even if the paraesophageal hernia has no obvious symptoms. Paraesophageal hernia Figure 5 Paraesophageal hernia Full gastric hernia into the thorax As the type II hernia increases, the esophagus membrane usually thins and expands and the stomach continues to deform. Drag the gastric cardia upwards, and once it is out of the esophageal hiatus, the diaphragm When it is above, it is called mixed esophageal hiatal hernia (type III). Some people think that when multiple abdominal organs, such as the colon and small intestine, enter the paraesophageal hernia sac at the same time, it should be called multiple organ hiatal hernia (type IV). Mixed hiatal hernia esophageal hiatal hernia is more common in men and older, and its clinical symptoms are caused by gastroesophageal reflux or hernia complications. Sliding hiatus (type I) rarely causes symptoms, and special symptoms only occur when pathological reflux is combined; paraesophageal hernia can cause symptoms without reflux, and symptoms are caused by complications. The clinical manifestations of patients with paraesophageal hernia vary according to the content of the hernia. The common clinical features are premature infection and fullness during eating, vomiting after eating a lot, discomfort in the upper abdomen, difficulty swallowing, and rattle. Difficulty swallowing is caused by the hernia's viscera pressing the esophagus from the outside. The viscera that hernias into the chest squeezes the lungs and occupies part of the chest, which can cause coughing and difficulty breathing after meals. If the hernia contents are obstructed, narrowed, necrotic or perforated, the patient may have symptoms of shock and gastrointestinal obstruction, and severe cases can often be fatal. Gastric regurgitation manifests as discomfort and acid reflux behind the sternum, and the discomfort occurs from the xiphoid to the throat, with a burning sensation in severe cases. Symptoms can be exacerbated by playing, lifting weights, hard stools, eating or taking antacids. The feeling of upper abdominal pain is often atypical and may be caused by acute esophageal contracture. The nature of pain is similar to peptic gastric and duodenal ulcers, biliary angina, and angina pectoris. Pay attention to the difference. The pain of hiatal hernia is radiated to the lower back and even to the upper limbs and jaw. It can be induced by swallowing activity and worsened by hot drinks or alcohol. If angina cannot be ruled out, the patient should be admitted to the monitoring room for further examination. Gastric reflux can also cause sore throat, burning sensation in the mouth, and even irritation of the vocal cords resulting in hoarseness. Difficulty swallowing is a common symptom of reflux. In some patients, there is no esophagitis, and dysphagia may be caused by varying degrees of esophageal spasm or poor esophageal contraction. In patients with esophagitis, dysphagia can only be found when eating hard food when it develops into a significant constriction. Eating hot food, cold drinks, or alcohol can all increase heartburn. As the esophageal constriction gets worse, the amount of gastric juice flowing back to the esophagus decreases, and the burning sensation gradually decreases. Difficulty swallowing caused by diffuse esophageal spasm is different from narrowing. The former is paroxysmal. Regardless of the case of eating a solid or liquid food with motor dysfunction, it is difficult to swallow or feel a neck mass when swallowing. Misdiagnosed as Hydatid disease. A small number of patients have difficulty swallowing due to food blockage in the esophagus. Aspiration caused by reflux of gastric juice is common in patients in the supine regurgitation mode at night, which usually forces patients to wake up due to cough aspiration. Severe aspiration can cause lung abscesses, repeated pneumonia, and bronchiectasis. Hoarseness in the morning is another symptom of aspiration at night. Gastric regurgitation occasionally causes asthma, and the issue is still controversial. However, an asthma sufferer may develop more frequently due to reflux of gastric fluid. Bleeding caused by reflux esophagitis is rare, and ulcerative esophagitis can be chronic hours, positive fecal occult blood, which can lead to anemia; it can also be acute massive bleeding, vomiting or melena, causing hemorrhagic shock. Stools are often caused by diffuse ulcer bleeding in the esophagus or by penetrating ulcers in the gastric mucosal area lined up in the distal esophagus. These patients urgently need surgery.

Treatment of hiatal hernia

Esophageal hiatal hernia medication

Most sliding esophageal hiatal hernias are minor, and mild and moderate esophagitis are common in Chinese people. These patients should be treated firstly for medical treatment. Can take antacids, adjust diet, avoid activities that increase abdominal pressure, take a high pillow position, sleep on the left side and other measures during sleep. If reflux esophagitis has progressed to grade III, surgery should be considered to avoid esophageal stenosis. Paraesophageal hernia should be treated early with or without symptoms; mixed hiatal hernia should also be treated with surgery to avoid complications of gastric obstruction and narrowing. Regarding the medical treatment of reflux esophagitis, such as the use of antacids, alginic acid or antacid compounds can alleviate the symptoms and reduce inflammation, but most of them use H2 receptor blockers, and their efficacy is relatively positive. In severe cases, omeprazole (Losec) is superior to conventional doses of ranitidine. Although all antacids have short-term effects, they do not change their natural course, and the recurrence rate is higher after discontinuation. Therefore, ultimately, hernia repair and antacid surgery are needed.

Esophageal hiatal hernia surgery

1. Surgical indications and contraindications Surgical treatment of esophageal hiatal hernia mainly considers its anatomical defect itself. Paraesophageal hernias, mixed hiatal hernias, and multiple organ hiatal hernias may be complicated by cramping or strangulation of the abdominal wall or other hernias. As the contents of the huge hernia squeeze the lungs, early surgery should be performed despite no obvious symptoms. Asymptomatic sliding hiatal hernia is only followed in the portal rash, without surgery. Sliding hiatal hernia with reflux esophagitis should be considered for surgical treatment when it develops to ulcerative esophagitis, narrowing or bleeding of the esophagus, or recurrent infection of the lungs due to reflux. About the esophagus covered by columnar epithelium. To prevent cancer, surgery has also been advocated. Contraindications to surgery: Surgery is contraindicated in patients with acute infection, severe heart and lung failure, and liver and kidney damage and patients with advanced cancer. Multiple esophageal hiatal hernias occur in older men, and age alone is not a contraindication for surgery unless there are obvious signs of aging.

2. Surgical methods The treatment of hiatal hernia and reflux esophagitis should include repairing the loose esophageal hiatus, extending and fixing the subsacral esophagus, and reconstructing the anti-acid valve mechanism. There are many ways to treat reflux esophagitis and its complications, and the choice of surgery depends on the situation of the specific patient and surgeon. The factors that must be considered before choosing a surgical method include: unfavorable chest or abdominal surgery; whether the patient has a history of anti-reflux surgery; whether the esophagus needs to be removed or the esophageal myotomy is performed; and how is the patient's physique? Surgical practice shows that for patients with extensive and severe esophagitis, the thoracic approach is conducive to free esophagus and easy gastric fundus operation; patients who have previously undergone antacid surgery and inevitably fail due to free esophagus should use the thorax approach. In the case of obesity, the exposure through the penetrating incision is more adequate, and the combined treatment of lung or mediastinal disease is more aggressive. For patients with esophagitis that is not too obese, the abdominal route can be used for the first antacid operation. When combined with abdominal diseases requiring surgery, the abdominal approach can also be used. Repair of paraesophageal hernias is often performed on the chest or abdomen. Regarding sutures, absorbent sutures and acid-resistant absorbent sutures have been used before. Currently, most surgeons use non-absorbable sutures and non-invasive non-absorbable sutures. At present, operations for repairing a sliding esophageal hiatal hernia and correcting gastroesophageal reflux include fundoplication, partial fundus folding, anatomical repair, and repair using ligament flaps.

Fundoplication: Nissen reported fundoplication in 1956, and his early results were reported in 1963. In 1973 Rossetti reported his modified fundus fold. Nissen calls his fundoplication "valvuloplasty." Use the bottom of the stomach to completely surround the lower esophagus, and sew to the small curved side of the right side of the esophagus. In this way, the positive pressure in the stomach is transmitted to this newly formed "collar" surrounding the esophagus and compresses the esophagus. When the pressure in the stomach is the function of this one-way valve, food can enter the stomach from the esophagus, but it cannot flow back into the esophagus from the stomach. Symptoms in 875 patients disappeared with a mortality rate of 0.6%, and the recurrence rate of hernia and reflux esophagitis was about 1%.