View Full Version : HIATUS HERNIA (Aetiology-Types-Clinical Picture-Treatment)

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04-21-2008, 11:24 AM
Definition: Protrusion of part of stomach through oesophageal hiatus of diaphragm into the thorax.
Aetiology: Weakness in the ligament supporting oesophagus at its place (Rt. & Lt. crura of the diaphragm) acted upon by increase intragastric pressure due to pyloric obstruction or increase intra-abdominal pressure in cases of prostatic enlargement cough, constipation and enlarged prostate .

1- Sliding 85% 2- Para-oesophageal 10% (Rolling type)
3- Mixed 5%

* The congenital short oesphagus can be considered as a type of H.H.
1- Sliding type, 85%:
The stomach is pulled up to the thorax with its peritoneal covering.
The oesophagogastric junction will ascend to the chest which interfere with the mechanism preventing gastric reflux.
2- Para-oesophageal 10% (Rolling) type:
The oesophago gastric junction remains at its normal place but a sac is present in the Lt. side of the hiatus which may contain a part of the fundus of the stomach
The cardia is competent & the patient suffer no reflux.
3- Mixed type 5%:
Combination between the 2 above types.
Factors maintaining competence of oesophago-gastric junction:
1- Intrinsic functional lower oesophageal sphincter.
2- Abdominal part of the oesophagus is compressed by high abdominal pressure.
3- Pinch-cock effect of right crus of the diaphragm on the intra-abdominal oesophagus.
4- Oblique insertion of oesophagus into the stomach creating the angle of His.
5- Rosette shape distribution of the mucosa of the lower end acting as a valve.

Clinical Picture:
1- G.I.Tsymptoms Dyspepsia, dysphagia Reflux oesophagitis.
These symptoms are marked in sliding type.
2- Cardio- respiratory symptoms Tachycardia and Dyspnea.
These symptoms are marked in rolling type.
(1) Ba-meal in Trendlenberg position. (2) Oesophagoscopy
(1) Asymptomatic No treatment
(2) Mild cases: Conservative treatment
Raising the head in the bed. Antacid.
(3) Severe cases: Excision of the sac & repair of the defect through abdominal or thoracic approach.
a) Transthoracic repair: (Belsy's method) Left posterolateral thoracotomy through the Lt. 6th intercostal space
b) Transabdominal:
Hill's procedure. (posterior gastropexy)
Nissen's fundoplication. Plication of the gastric fundus around the lower oesophagus.
(4) Cases with reflux:
a) Leigh Collis gastroplasty: If the oesophagus is short due to previous oesophagitis. A tube of stomach is made which has the effect of extending the oesophagus into the abdomen. The oesophageal hiatus is then reduced in size around this tube.
b) Angelchik prosthesis: A plastic ring is placed around the oesophago-gastric junction
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