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Julio Alejandro Murra-Saca MD.
Gastroenterologist,
Tel : (503) 226-3131, (503) 225-3087, Celular (503) 887-2507
Email
  
Edificio Centro Scan, Colonia Médica, San Salvador, El Salvador.

 

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Notes on Cyber Gastroenterology

 
The diaphragm is a flat sheet of muscle tissue that separates your chest from your abdomen. Normally, all of your stomach organ is below the diaphragm. To reach your stomach, your esophagus, or "food pipe," travels down through the center of your chest and through an opening in the diaphragm. This opening is called the hiatus.


Often as one ages, the hiatus enlarges. This allows the top portion of the stomach to slip upward into the chest cavity. That portion of the stomach which rises above the diaphragm is the hiatal hernia. The name is derived from the fact that the stomach pushes, or herniates, through the hiatus - hence the name "hiatal hernia." This condition is quite common, but usually there are no symptoms. Activities or conditions that increase pressure within the abdomen may worsen the condition. These include persistent or heavy coughing, vomiting, straining while having a bowel movement, extreme exercises to tighten the "abs," sudden physical straining, and pregnancy.

The food goes down OK, but now the powerful stomach acid splashes up and damages the delicate lining of the lower esophagus. This condition is common and given the name, Gastroesophageal Reflux Disease, or GERD. See Heart burning
 
Sliding hernia Type I or sliding hiatal hernia accounts for more than 95 percent of cases. This type of hernia is characterized by widening of the muscular hiatal tunnel and circumferential laxity of the phrenoesophageal membrane, allowing a portion of the gastric cardia to herniate upward. The phrenoesophageal membrane remains intact and the hernia is contained within the posterior mediastinum
In marginal instances, type I hiatal hernia is simply an exaggeration of the normal phrenic ampulla, making its identification dependent on measurement technique. However, when a sliding hiatal hernia enlarges further, so that more than 3 cm of gastric pouch is herniated upward, its presence is obvious regardless of technique because gastric folds are evident traversing the diaphragm both during swallow-induced shortening and at rest. The progression from normal anatomy to obvious type I hernia is well illustrated in an analysis of the endoscopic appearance of the cardia, as viewed from beneath with the endoscope directed toward the hiatus
The etiology of most sliding hiatal hernias is speculative, but there are instances in which trauma, congenital malformation, and iatrogenic factors can be clearly implicated. The incidence of type I hiatal hernia is also unclear. Estimates of prevalence vary enormously, from 10 to 80 percent .
In all probability, most small hiatal hernias are asymptomatic and, even with larger type I hernias, the main clinical implication is the propensity to develop gastroesophageal reflux disease (GERD). The likelihood of symptomatic gastroesophageal reflux increases with the size of the hiatal hernia. It is rare for complications other than reflux to occur as a result of a type I hiatal hernia; furthermore, even these complications are usually related to reflux.
SYMPTOMS Hiatal hernia is not a diagnosis that is pursued in and of itself. It is usually discovered as a finding on upper gastrointestinal studies or endoscopy. Many patients with a type II hernia are either asymptomatic or have only vague, intermittent symptoms. The most common symptoms are epigastric or substernal pain, postprandial fullness, substernal fullness, nausea, and retching. An upright radiograph of the thorax may be diagnostic, revealing a retrocardiac air-fluid level within a paraesophageal hernia or intrathoracic stomach. Barium contrast studies are almost always diagnostic.
Most complications of a type II hernia are reflective of the mechanical problem caused by the hernia.

Type II, III, and IV: Paraesophageal hernias

Association of type I hiatus hernia with gastroesophageal reflux Endoscopic and radiographic studies suggest that 50 to 94 percent of patients with GERD have a type I hiatal hernia compared to 13 to 59 percent of normals. However, the importance of a type I hiatal hernia is obscured by the misconception that this is an all or none phenomenon. It is more useful to view type I hiatal hernia as a continuum of progressive disruption of the gastroesophageal junction . Type I hiatus hernia impacts on reflux both by affecting the competence of the gastroesophageal junction in preventing reflux and in compromising the process of esophageal acid clearance once reflux has occurred.

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