[Download]Paraesophageal Hernia: Current Management [PDF]

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Laura Mazer, MD, MHPE, Dana A. Telem, MD, MPH*
Department of Surgery, Division of Minimally Invasive Surgery, University of Michigan, 1500 E.
Medical Center Dr., Ann Arbor, MI 48109, USA

INTRODUCTION
First described in 1853 by Henry Bowditch as a ‘‘very curious dilation of the
esophageal opening,’’ hiatal hernia is present in up to 50% of the population [1].
These hernias are classified into four types based primarily on the location of
the gastroesophageal junction (GEJ) (Fig. 1):
 Type 1: Sliding hernias, the GEJ slides through the hiatus into the thoracic
cavity. Approximately 95% of hiatal hernias are of type I. Frequently associated
with gastroesophageal reflux disease (GERD)
 Type II: ‘‘True’’ paraesophageal hernias, occur when the posterolateral phre-
noesophageal attachments are preserved. The GEJ remains below the dia-
phragm and the gastric fundus herniates anteriorly
 Type III: Mixed type, where both the GEJ and the gastric fundus herniate into the
mediastinum

Presentation
Sliding hernias most commonly present with symptoms of GERD, but this is a
less common presentation for PEH. The presentation ranges from an incidental
finding in an asymptomatic patient to an acute presentation with gastric
volvulus and impending ischemia (Table 1). The typical patient is an elderly
woman beyond the 6th decade of life, and the condition is more common in
Western populations [3]. Symptoms for PEH are classified as obstructive or
nonobstructive. Nonobstructive symptoms include GERD, esophagitis, or
chronic anemia from Cameron’s lesions (mucosal ulceration at the level of
the diaphragm). Obstructive symptoms include dysphagia, regurgitation,
epigastric pain, early satiety, postprandial fullness, chest pain, or shortness of
breath. Shortness of breath can be mechanical, especially if it is postprandial,
or a sequelae of repeated lung injury from microaspirations. It is common
for patients to present with chest pain or shortness of breath and undergo a
workup for cardiac or pulmonary disease with eventual discovery of a PEH
as the cause of the symptoms.

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