hiatal hernia
Introduction
Introduction to esophageal hiatus hernia Hiatushernia refers to a disease caused by the intra-abdominal organ (mainly the stomach) entering the chest through the hiatus of the esophagus. Esophageal hiatus hernia is the most common in sputum, reaching more than 90%. Patients with esophageal hiatal hernia can be asymptomatic or mild, and the severity of the symptoms is not related to the size of the hernia sac and the severity of esophageal inflammation. Both hiatal hernia and reflux esophagitis can exist separately and distinguish between the two, which is important for clinical work. basic knowledge The proportion of illness: 0.03% Susceptible people: no special people Mode of infection: non-infectious Complications: reflux esophagitis upper gastrointestinal bleeding gastric torsion gastric ulcer
Cause
Cause of esophageal hiatal hernia
Congenital dysplasia (45%):
Under normal circumstances, there are tough connective tissues around the stomach and esophagus (sacral esophageal ligament, gastric ligament, gastric suspensory ligament) to make it closely connected with the surrounding, so that the stomach and esophagus remain in a normal position, preventing food reflux from entering the esophagus. To prevent abdominal esophagus, the esophagus moves up, if the esophageal ligament, gastric ligament, gastric suspensory ligament and other dysplasia, especially the esophageal ligament and the esophagus lost tight connection, the esophageal abdominal segment lose control and stability, when the diaphragm muscle movement Because the esophageal esophagus is highly active, it is easy to enter the thoracic cavity to form sputum. The autopsy found that the connection between the periphery of the esophageal hiatus and the esophageal wall of some neonates is tightly connected to the anterior and posterior wall of the esophagus, and the sides are slack. Therefore, the contents of the sputum easily enter the chest from the weak places on both sides of the esophagus.
Acquired factors (25%):
The esophageal ligament degeneration, relaxation: the esophageal ligament is present in the neonatal period. With the increase of age, the tissue around the esophageal hiatus and the elastic tissue of the esophageal ligament atrophy and become thinner and weaker, while the subperitoneal fat gradually accumulates. Near the hiatus, the esophageal hiatus is widened. Because the esophageal ligament and other fascia around the esophagus degenerate and relax, gradually losing the function of fixing the lower esophagus and the cardia in the normal position, it is easy to make the lower esophagus and the sacral sac. With the increase of age, the incidence of adult esophageal hiatal hernia is gradually increasing. It is confirmed in surgery that the esophageal ligament of many adult esophageal hiatal hernias has virtually disappeared, especially in the elderly, the above-mentioned degeneration and atrophy are very common, and More often associated with increased abdominal pressure (such as constipation, prostatic hypertrophy, chronic bronchitis, etc.), in the esophageal hiatus widening and high abdominal pressure on the stomach to the chest cavity "push" effect, more susceptible to disease.
Disease factor (10%):
Esophageal contracture: chronic esophagitis, lower esophageal diverticulum, ulcer, tumor infiltration, thoracic kyphosis, strong vagus nerve stimulation can cause esophageal contracture, esophagus in the long-term upward traction, the lower esophagus and cardia gradually enter the sputum The disease.
Physical factors (5%):
Surgery and trauma: Severe chest and abdomen injury, surgical esophagus, normal position of the stomach and esophageal hiatus, or relaxation of the esophageal ligament and hiatus of the esophageal sac caused by surgical traction can also cause the disease.
Pathogenesis
The enlargement of the esophageal hiatus, the weakening of the diaphragmatic muscle around the esophagus, etc., causes the esophagus, cardia or fundus of the abdomen to increase with abdominal pressure, enter the mediastinum through a wide hole, and cause a series of pathological changes such as gastroesophageal reflux and esophagitis. .
1. Pathological classification: There are many pathological methods, and the following four types are common:
(1) Akerlund classification: Akerlund (1933) classified esophageal hiatus into type 3.
Type I (congenital short esophageal hiatal hernia): congenital short esophagus, the stomach is pulled into the chest; or the defects in the development of congenital esophageal hiatus are too broad, the stomach into the chest and the secondary esophagus becomes shorter.
Type II (paraesophageal hernia): The cardia is located in the normal position of the armpit. Some of the fundus and the covered peritoneum are inserted into the thoracic cavity from the esophagus. The cause of the disease may be congenital dysplasia or acquired factors.
Type III (esophageal gastric snoring): This type is the most common, the gastroesophageal junction is smashed into the sacral, the sac is located in the posterior mediastinum, the His angle becomes obtuse, there is no real sac, the esophageal ligament is elongated, relaxed, stomach The left artery is also pulled up and up. When standing, the stomach that has entered the sputum can return to the abdominal cavity partially or completely.
(2) Shinner classification: According to anatomical defects and clinical manifestations, esophageal hiatus is divided into 4 types:
Type I (esophageal hiatus): mild dilatation of the esophageal hiatus, thinning of the esophageal ligament, uplift of the cardia and fundus, and varying degrees of stomach and esophageal reflux.
Type II (paraesophageal fistula): a defect in the esophageal ligament, a hernia sac formed by the peritoneum, normal position of the cardia, no stomach, and esophageal reflux.
Type III (mixed type): the esophageal hiatus sliding sputum and the esophageal paralysis exist simultaneously, with stomach, esophageal reflux.
Type IV (multi-organ type): Part of the colon or small intestine also enters the esophageal hernia sac.
(3) Allison classification: a total of 5 types, type I: esophageal paralysis; type II: paraesophageal paralysis; type III: sliding sputum; type IV: esophageal cystic sliding sputum; V type: congenital short esophagus.
(4) Barrett classification: Barrett according to the extent of esophageal hiatus development defects, the amount of content into the chest cavity, pathological and clinical changes, the esophageal hiatus is divided into 3 types (Figure 8).
Type I: esophageal hiatus sliding sputum; type II: esophageal paralysis; type III: mixed sputum.
Because Barrett is simple and practical, it is widely used at home and abroad.
2. Pathophysiology: Explain according to the Barrett classification method.
(1) Esophageal hiatus sliding sputum: the ankle ring is a large esophageal hiatus, the content of the sputum is the esophageal abdominal cavity, the cardia and the fundus, no real hernia sac, when the supine position or abdominal pressure increases, the esophageal abdominal cavity, the cardia And the fundus can be smashed into the sacral canal by a large esophageal hiatus; when the abdominal pressure is reduced or the stomach is empty, the esophagus and the sacral slid back to the normal position, most of the esophageal abdominal segment becomes shorter, and the stomach His angle becomes dull, due to the gastroesophageal junction And the fundus enters the posterior mediastinum, the lower esophagus is exposed to the negative pressure in the thoracic cavity, the sphincter function is lost, and gastroesophageal reflux occurs. It should be noted that the occurrence of gastroesophageal reflux is not all pathological, and normal people also Gastroesophageal reflux occurs, especially after eating. Simple gastroesophageal reflux does not necessarily lead to esophagitis and symptoms. The study found that the degree of damage to the esophagus by acidic stomach contents depends on the esophagus. The ability to clear the acidic stomach contents, the neutralization of alkaline saliva to gastric acid, the ability of the esophageal mucosa to resist acid erosion, etc., the ability of the esophagus to clear the acidic stomach contents and the esophageal peristalsis, gravity Close to the body position, especially the esophageal peristalsis function is more important. Under normal circumstances, the reflux can trigger the secondary peristalsis of the esophagus. Once the reflux occurs, the esophagus produces a strong peristaltic wave to exclude the esophageal cavity. The acidic content can quickly restore the acidity in the esophagus to the original level. When the early esophageal hiatus is small, the defects of the local anatomy can induce mild acid reflux, and the esophagus can enhance the esophagus through its own compensatory mechanism. The peristaltic function increases the acid scavenging capacity of the esophagus to avoid or reduce the damage of the esophageal mucosa. At this time, the gastroesophageal reflux with no morphological changes of the esophageal mucosa is present. When the reflux frequency or reflux flow exceeds a certain limit, or the peristalsis of the esophagus itself is insufficient. In order to remove the acidic reflux caused by reflux to the esophagus, its compensatory mechanism is destroyed, causing damage and inflammation of the esophageal mucosa under the attack of gastric acid and pepsin. The inflammation begins, confined to the lower esophageal mucosa congestion and edema, esophagus Esophageal motility abnormalities may occur in patients with hiatal hernia after reflux esophagitis, mainly manifested as distal esophageal motility disorder, The clearance ability of the fluid is further reduced. Under the stimulation of the gastric reflux for a long time, the inflammation of the esophageal mucosa is aggravated and destroyed, and ulcerative esophagitis is formed. The edema of the esophageal wall and the fistula of the esophageal muscle layer make the esophageal cavity. Narrowing, severe inflammation can involve the esophageal muscle layer or even the esophageal tissue, esophagitis and peri-inflammation of the esophagus, due to long-term recurrent episodes of esophagitis, collagen coverage and granulation tissue proliferation during ulcer healing, resulting in thickening of the esophageal wall, Stiffness eventually leads to esophageal fibrosis, scarring of esophageal stenosis and/or shortening, and even obstruction. Skinnex reports that the incidence of esophageal stricture in adults with reflux esophageal hiatus hernia is 20%, and that of children is 35%. Especially in the elderly patients aged 60 to 80 years old.
The lower esophageal sphincter can be temporarily relaxed, and the frequency of transient relaxation of the night sphincter is higher than during the day, combined with high nighttime gastric acid secretion (high vagal excitability), decreased esophageal peristalsis, less saliva to neutralize gastric acid, and reflux mainly gastric acid. And pepsin composition (no food in the stomach) and other factors, so patients with esophageal hiatus sliding sputum have more chances of esophagitis at night, reflux is absorbed into the larynx and trachea, inflammatory polyps can occur in the vocal cords, but also due to aspiration Repeated pneumonia, bronchitis, a small number of inhaled foreign bodies left in the lungs can cause lung abscess or bronchiectasis, can also induce asthma attacks, especially newborns, infants are most prone to aspiration, some infants and young children often sleep Gastroesophageal reflux occurs in the middle, and the reflux is inhaled into the trachea and bronchi. Coughing, crying, and even suffocation of the newborn are often caused during sleep. Clinically, it is common to see patients with recurrent respiratory infections.
In the past, it was thought that the diaphragmatic dysplasia of the esophageal hiatus, the relaxation of the esophageal ligament, the dullness of the gastroesophageal His angle, and the abnormality of the esophageal peristaltic function are the causes of gastroesophageal reflux, and the apical His angle is changed by surgery. Sharp, repairing the enlarged esophageal hiatus has obtained a certain effect, and indirectly confirmed the relationship between the above factors and gastroesophageal reflux, but it is currently believed that the occurrence of gastroesophageal reflux is not related to the size and anatomic abnormality of the hiatal hernia, and the lower esophageal sphincter The formed physiological high pressure area plays an important role in the anti-reflux barrier. The function of the lower esophageal sphincter is mainly related to the length of the lower esophageal sphincter and the pressure of the lower esophageal sphincter. Some scholars believe that:
1 lower esophageal sphincter pressure <7mmHg.
2 lower esophageal sphincter function segment length <2cm, or esophageal abdominal cavity <1.0cm, indicating lower esophageal sphincter dysfunction, it has been confirmed that patients with esophageal hiatal hernia caused by lower esophageal sphincter length and lower esophageal sphincter pressure Abnormal, but some scholars believe that the lower esophageal sphincter pressure in patients with esophageal hiatal hernia is not abnormal, and the lack of length of the lower esophageal sphincter is the main cause of lower esophageal sphincter dysfunction. Domestic scholar Zhou Xuelian and others also found in clinical research. Lower esophageal sphincter pressure does not play an important role in the occurrence of gastroesophageal reflux in patients with esophageal hiatal hernia; the esophageal ventral segment serves as the site of the lower esophageal sphincter functional unit, and its length constitutes an integral part of the lower esophageal sphincter function, which is restored by surgery. The length of the esophageal intestine is anti-reflux, and its curative effect is closely related to the length of the esophageal segment in the postoperative period. The mild effect is good, indicating that the insufficient length of the esophageal ventral segment is the key cause of reflux.
(2) Esophageal fistula: There is a crypt on both sides of the early esophagus in the embryo. If it does not disappear during the development process, it forms a weak link, and the diaphragmatic dysplasia leads to the enlargement of the esophageal hiatus. The fundus can be defected or weakened. On the upper side of the esophagus, the esophageal fistula is formed. At this time, the cardia is still located under the armpit, the stomach His angle is unchanged, the esophageal abdominal cavity is kept at a certain length, the lower esophageal sphincter function is not abnormal, and a good anti-reflux mechanism is maintained. No gastroesophageal reflux phenomenon, large stomach curvature and part of the stomach or whole stomach can also break into the chest cavity, forming a huge esophageal fistula, such as the whole stomach flipped into the chest along the long axis of the cardia and pylorus, which can lead to gastric torsion Obstruction, as the whole stomach enters the mediastinum, the swallowed air can not be discharged, the gastric swell is aggravated, the blood supply disorder gradually occurs, the necrosis is narrowed, the perforation occurs, and severe chest, abdominal infection and toxic shock occur.
(3) mixed sputum: obvious relaxation of esophageal ligament can not fix the esophagus, cardia, causing it to slide up and down the esophageal hiatus, and the bottom of the stomach into the chest cavity, both the stomach His angle becomes dull, the lower esophageal sphincter function is lost, the gastroesophageal Flow, and the stomach can be broken into the chest and twisted.
Prevention
Esophageal hiatal hernia prevention
Esophageal hiatus hernia is rare in children under 40 years old. With the increase of age, the loosening of supporting tissues around the esophageal hiatus occurs. When suffering from chronic diseases, it is more likely to weaken the diaphragmatic muscles and expand the hiatus. Another important factor is the abdomen. The increase of internal pressure, pushing the upper stomach to the loose hole, resulting in various factors of increased abdominal pressure, as mentioned in the brief description, in addition, abdominal blunt trauma caused a sudden increase in abdominal pressure, can also induce this disease, people to In the year, the disease should be based on prevention. For some anemias with unknown causes, upper gastrointestinal bleeding, pain in the precordial area, it is necessary to think of the disease as soon as possible and GI or endoscopy.
Complication
Esophageal hiatal hernia complications Complications reflux esophagitis upper gastrointestinal bleeding gastric torsion gastric ulcer
1. Complications of esophageal hiatus sliding hernia
Due to the reflux of gastric acid, the following complications can be caused.
(1) Reflux esophagitis:
Skinner reported 1168 patients with esophageal hiatal hernia (78% of esophageal hiatus hernia, about 8% of esophageal parasitism) 60% found esophagitis, 14% had reflux and asymptomatic; gastroesophageal reflux mainly occurred in esophagus Sliding hiatus, only 30% of esophageal paralysis is accompanied by reflux, gastroesophageal reflux can also occur under normal conditions, but most of the reflux is quickly cleared from the lower esophagus, without any symptoms, and does not cause esophageal mucosa The damage of the esophageal hiatus slide due to dysfunction of the lower esophageal sphincter and gastroesophageal reflux, especially in the esophageal acid gastric emptying delay can occur in the esophageal mucosal injury, when the reflux of the stomach contents and prolonged contact with the esophageal mucosa, Stimulation can lead to the destruction of mucosa to form ulcerative esophagitis, long-term recurrent episodes, eventually leading to esophageal fibrosis, esophageal stricture and/or shortening. In different stages of esophagitis, patients may have post-sternal burning pain and difficulty swallowing. And other symptoms.
Some scholars believe that the extent of esophageal hiatal hernia complicated with reflux esophagitis and reflux esophagitis depends on the function of the cardia, lower esophageal sphincter, and the esophageal hiatus sliding sputum in the function of the lower esophageal sphincter and the sphincter There is neither gastroesophageal reflux nor reflux esophagitis; when the cardia sphincter is insufficiency and the lower esophageal sphincter is functioning properly, the gastroesophageal junction and the hernia sac lose the barrier against gastroesophageal reflux. The gastric juice can reciprocate at the gastroesophageal junction, causing reflux esophagitis below the lower esophageal sphincter plane; when the functions of the cardia sphincter and the lower esophageal sphincter are lost, the gastric juice can be refluxed to the esophageal part above the lower esophageal sphincter plane, resulting in Diffuse esophagitis.
(2) Obstruction:
Early esophagitis, esophageal wall edema and esophageal spasm caused by narrowing of the esophageal lumen; advanced esophageal fibrosis to form scarred esophageal stenosis; esophageal fistula compression esophagus can also cause esophageal obstruction, mainly as food stagnation, Dysphagia and difficulty swallowing.
Food stagnation refers to the feeling of food stagnation in the lower part of the sternum after swallowing. It is caused by food retention in the sac and sac compression of the esophagus. The bolus temporarily stays in the esophageal inflammatory area or in the uncoordinated area of motor function, which may cause some It is felt that the patient can simply feel that the food or liquid is stopped above the esophagus, waiting for the group to descend down or drinking water; sometimes it is illusory to feel that the group is blocked in the esophagus.
Dysphagia, difficulty in swallowing mostly due to esophageal ulcer or stenosis, caused by esophageal fistula, mostly in eating rough, overheated or too cold food after the attack, partial or complete obstruction of food swallowing, does not necessarily occur pain, hypopharyngeal solid Food difficulty indicates stenosis, and difficulty in hypopharyngeal fluid is mainly abnormal motor function. Unexpected sudden discharge occurs sometimes when drinking liquid. This is due to uncoordinated esophageal movement, and another feature is difficulty in swallowing the first mouth. It is difficult to swallow a few mouthfuls of food. It is easier to swallow, but it is always slower than others. The location of food obstruction depends on the length of the esophageal stricture and the size of the hiatal hernia. The general patient feels obstruction. The area is higher than the anatomical part. Edema and sputum can cause food to stop obviously through the stenosis, but it can pass through endoscopy. As the stenosis progresses, the food enters the stomach very slowly, and accumulates in the esophagus after eating until the nausea or High dysphagia occurs.
(3) Upper gastrointestinal bleeding:
Mostly caused by esophagitis, esophageal ulcer, about one-third of patients have no obvious symptoms of esophagitis, usually manifested as chronic small amount of bleeding and iron deficiency anemia, accounting for about 80% of upper gastrointestinal bleeding caused by this disease, occasionally It is characterized by severe iron deficiency anemia. Diffuse esophagitis or esophageal ulcer can sometimes cause severe hematemesis. Chronic blood loss is mostly positive for fecal occult blood test, and melena is rare.
(4) Respiratory symptoms: Abnormal gastroesophageal reflux can cause laryngeal and lung lesions. When the reflux often passes through the pharyngeal sphincter into the hypopharynx, it can be accidentally inhaled into the larynx and trachea, causing inflammatory polyps in the vocal cords. Aspiration can lead to bronchitis, recurrent pneumonia, and in a few cases, inhaled foreign bodies can cause lung abscess or bronchiectasis in the lungs, and can also induce asthma attacks.
2. Complications of paraesophageal fistula
(1) gastric torsion, strangulation, acute gastric dilatation and intestinal obstruction:
When the whole stomach enters the mediastinum, the swallowed air can not be discharged, and the stomach enlargement is aggravated. It manifests as chest tightness, respiratory disorder, abdominal pain, vomiting, vomiting is brown or bloody stomach contents, if there is organ strain, necrotic perforation, etc. Emergency can cause sudden collapse of the patient, atelectasis of the lungs, mediastinal inflammation, bronchial pneumonia, and even death.
(2) gastric ulcer:
Rarely, clinicians lack understanding, which may lead to misdiagnosis and mistreatment. The incidence is difficult to estimate. It is reported that the detection rate of barley meal accounts for 1% to 5% of cases, and the endoscopy detection rate is 6% to 8%. .
It often occurs on the contralateral side of the defect of the iliac crest, or on the side of the small curved side of the stenosis. The dorsal side of the stiff sulcus leading to the center of the iliac crest is related to local mechanical stimulation, chemical stimulation, and during the respiratory movement. The diaphragmatic foot can cause continuous damage to the stomach wall of the reciprocating movement. In addition, the long-term stimulation of gastric contents such as stomach acid in the stomach of the hernia sac can also cause damage to the gastric mucosa, mechanical damage and chemical stimulation. The blood stasis of the gastric wall in the sac of the sac is combined with the erosive damage of the gastric mucosa to form a gastric ulcer.
Some people think that bleeding in the stomach ulcer is the main cause of anemia in the patients. Some scholars found in a group of 69 cases of gastric ulcer in the sac of the sac in the clinical observation, 74% of the upper gastrointestinal bleeding, especially the esophageal paralysis See, so when the patient has upper gastrointestinal bleeding, should be alert to the presence of gastric ulcer. In addition to the type of sputum, it is related to the size of the sputum and the recoverability of the sputum. It is generally considered that the diameter is greater than 5cm or incarcerated hiatal hernia is prone to major bleeding.
Intraorbital gastric ulcer perforation is rare, the incidence of which accounts for 7% of cases of symptomatic intra-orbital gastric ulcer, or 0.5% of cases with symptomatic esophageal hiatal hernia, more common in elderly patients around 70 years old, with a long history, and most It is an incarcerated hiatal hernia. If abdominal pain or upper gastrointestinal bleeding occurs in the near future, the possibility of perforation of gastric ulcer may be considered. In some cases, perforation may break into the pleural cavity, pericardium and right ventricle. Perforation of the thoracic cavity and its organs is difficult to determine clinically. Localized perforation of gastric ulcer can be localized by adhesion of adjacent tissues. Free perforation under the armpit can cause diffuse peritonitis or underarm abscess; Causes mediastinal inflammation or mediastinal abscess, pericarditis, pericardial abscess or thoracic abscess, occasionally due to perforation to the pulmonary artery, aortic and coronary artery caused by massive bleeding and death.
X-ray barium meal examination has a low detection rate of gastric ulcer in the sputum. It is reported that it is only 37%, but barium meal examination can show two risk factors of gastric ulcer and blood and perforation.
Symptom
Esophageal hiatal hernia symptoms Common symptoms Hernia stomach incarcerated snoring nausea esophageal peristalsis weakened dull pain abdominal discomfort nausea hiccups can not tolerate polylipid diet
1. Burning pain or pain or pain or tightness in the back of the sternum or upper abdomen. The pain spreads widely. It occurs 30-60 minutes after a meal. It can be induced by bending down and lying down, and there is also precordial pain or total chest pain. A small number can be manifested as acute abdomen. The pain relieved within 1 hour. When the esophageal fistula was incarcerated, sudden upper abdominal pain suddenly occurred, accompanied by vomiting and difficulty in swallowing.
2. Reflux symptoms: hernia, acid reflux, heartburn, hiccups, vomiting, etc.
3. Obstructive symptoms: When part of the stomach is in the chest or esophagitis, the esophagus is narrowed or paralyzed. When eating, there is a sputum, the lower pharynx is not smooth, or the food is stagnated behind the sternum. It is intermittent, and it can be persistent for a long time.
Examine
Esophageal hiatus hernia
Esophageal hiatus hernia laboratory test
Hemoglobin
Infants and young children with hiatal hernia and dysplasia, or chronic hemorrhage of gastric ulcer in the esophageal hiatus hernia, hemoglobin will be reduced.
2. Fecal occult blood test
Diffuse esophagitis and gastric ulcer in the sac is associated with chronic blood loss, and the fecal occult blood test is positive.
Imaging examination of esophageal hiatus hernia
Electrocardiogram
Patients with esophageal hiatal hernia may have pain in the anterior region of the esophagus, and the vagus nerve may be stimulated by the onset of pain and the coronary blood supply may be insufficiently reflected. The electrocardiogram may have myocardial ischemic changes, which is clinically similar to coronary heart disease and is called esophageal-coronary artery synthesis. Sign.
2. X-ray inspection
As early as the 20th, 40th, and 50s of the 20th century, Akerlund, Kirklin, and Wolf performed detailed X-ray examination of hiatal hernia, and a large number of clinical data showed that X-ray examination is the main method for diagnosing hiatal hernia. The shape, location, size of the esophageal hiatus and changes in gastric peristalsis.
(1) fluoroscopy or chest radiograph: the X-ray plain film of the esophageal paralysis has the following characteristics: 1 the posterior mediastinum has a stomach bubble shadow, the positive film on the stomach is at the palpebral angle, and the lateral position is behind the heart shadow. The size varies with the amount of residual gas in the stomach; 2 because part or most of the stomach breaks into the chest cavity, the left upper abdominal stomach bubble shrinks, and even the stomach bubble is not visible; 3 the inserted stomach tube is in the chest cavity.
(2) Esophagus and gastric angiography: neonates, infants and young children use air or water-soluble contrast agents (such as 12.5% sodium iodide) to prevent sputum inhalation into the respiratory tract, older children, adult patients can choose Dilute barium angiography.
1The characteristics of the sliding sac: The typical performance is: A. The end of the esophagus, the gastroesophageal junction, part of the stomach through the esophageal hiatus to the iliac crest, and other parts are located under the left ankle; B. Stomach and sputum on the sputum It is umbrella-shaped, or the upper part is swollen obviously, and the mucosal folds are thickened; C. The fundus and the cardia move up and down in the center of the diaphragm with the body position; D. The esophageal abdominal cavity is shortened, straightened, and the His angle becomes dull; E. There is esophageal fistula X-ray signs of esophagitis, such as relaxation and widening of the cardia, or gastroesophageal reflux; F. Patients with advanced esophageal stenosis; G. esophageal dilatation, enlarged esophageal hiatus, under normal circumstances, maximal exhalation, esophageal hiatus opening, diameter 1.52cm; the maximum deep inspiratory hole is closed. The esophageal dilatation can be seen in this patient. The crest is more than 2cm, and the opening of the hiatus is obviously increased. According to the data of China Medical University, the esophageal hiatus opening of some children with giant esophageal hiatus hernia can reach 2.5. ~ 4cm, and the maximum deep inspiratory hole is not closed; H. The general lying position appears and the standing position disappears, especially some small esophageal sliding sputum, the patient's position is often the determinant of the sputum, because the small esophageal sliding squat Bit time More energy can also be returned, and the swallowing tincture quickly passes through the esophagus in the standing position, and the cardia enters the stomach. It is more difficult to display sputum. It can be used in the lower part of the head and slightly in the upper abdomen. Sliding into the chest; it is difficult to confirm the diagnosis by repeated X-ray examination, more can be diagnosed, and some sliding sputum angiography, the part of the sputum to the sac is not saclike expansion and columnar performance, the diagnosis is more difficult, such as Careful examination revealed that the gastroesophageal junction was actually diagnosed by the fact that the esophageal hiatus was indeed moved to the iliac crest.
2 The characteristics of the esophageal paralysis: A. The end of the esophagus is located under the diaphragm, in the abdominal cavity, the cardia is fixed in the normal position of the armpit; B. The fundus is mostly in the left side of the esophagus through the enlarged hiatus into the diaphragm, the lower part of the posterior mediastinum, The sacral sacral sign (thoracic stomach) is presented. When the barium meal is examined, the sacral sac is visible on the left side of the sac, which is round or oval. The diameter is more than 5cm. The appearance of the sac is not related to the esophageal peristalsis. Gastric mucosa shadow, and the widened esophageal hiatus continues to the bottom of the infraorbital stomach, and the sacral sac and esophageal shadow are not on an extension line; C. less signs of gastroesophageal reflux; D. The stomach is compressed, the esophageal sputum passes through the obstacle; E. can show the sputum in the sputum; the large esophageal sputum can be seen in most of the stomach or the whole stomach through the esophageal hiatus into the sputum, the stomach can be seen after the stomach twist On the top, the small bend is down and is inverted.
3 mixed type sputum: In addition to the above-mentioned signs, it can be shown that the esophageal fistula is moved up with the door opening, or the fundus of the esophagus sliding sputum is above the sacral sac, and the sputum agent flows back into the sacral sac.
(3) CT scan: Compared with chest radiograph, CT scan can accurately determine the contents of sputum, especially the retina, mesangial and substantial organs that are not easily found in conventional chest radiographs; the size and shape of esophageal hiatus can be found, It can provide a basis for the development of treatment plans; it can clearly distinguish between inflated bowel and balloon swelling, and can clearly show the filling of the gastrointestinal tract after oral administration of contrast agent. Therefore, when the chest plain film examination reveals abnormal shadow in the thoracic cavity and suspects When the esophageal hiatus hernia, in addition to conventional X-ray gastrointestinal angiography, CT examination should be performed. CT plain scan can not only confirm the diagnosis, but also can clearly break into the organ. If the content of the sputum is suspected to be the omentum, liver, spleen and kidney. When the organ is in the same time, it can be used for enhanced scanning; if the contents of the sputum are considered to be organs such as the gastrointestinal tract, the contrast agent can be orally administered before the enhanced scanning.
3.B-ultrasound
B-ultrasound examination of hiatal hernia is a non-invasive examination method, with clear image, convenient bedside inspection, can be repeated in a short period of time, free from radiation hazards, etc. The characteristics of the sound image are:
1 esophageal hiatus sliding sputum (type I): After drinking water, the cardia can be seen, the fundus is located above the diaphragm, and the contents of the stomach are rounded up and down the diaphragm.
2 Esophageal fistula (type II): After drinking water, the stomach cavity is filled rapidly, and the cardia is located under the armpit. It can be seen that the fundus or most of the stomach protrudes into the thoracic cavity through the esophageal hiatus. It changes in a "B" shape or dumbbell shape, and the boundary is clear. The content travels to and from the stomach cavity above and below the diaphragm.
3 hybrid type: with the above two characteristics.
Since Naik first applied B-ultrasound diagnosis of gastroesophageal reflux in 1984, the diagnosis of esophageal hiatus hernia and its complicated gastroesophageal reflux, esophagus, was mainly diagnosed by scanning the esophageal wall muscle thickness, esophageal diameter and its length. Patients with hiatal hernia have the characteristics that the esophageal abdominal cavity is shorter than normal, the diameter is increased, and the wall is thickened. If the esophageal abdominal segment is too wide and the gastric mucosa protrudes into the esophagus, it indicates that the esophageal hiatus is recurrent for a long time; if the esophageal abdominal cavity is mucosal The texture is disordered, suggesting a serious esophagitis.
4. Endoscopy
Endoscopy can directly understand the pathological changes of esophageal hiatus hernia, the condition of gastroesophageal reflux and the degree of esophagitis, not only provide an important basis for the diagnosis of this disease, determine the treatment plan, but also provide objective indicators for the judgment of efficacy.
(1) Mirror signs:
1 The gastroesophageal junction is moved up to the esophageal orifice ring, and the distance from the incisor to the esophagus and stomach junction becomes smaller.
2 more secretions in the esophageal lumen.
3 The door is slack, the mobility increases, and the width can be more than 2 times the diameter of the lens body.
4 gastroesophageal reflux, liquid retention in the esophagus; 5 sputum on the gastric mucosa.
6 esophagitis: due to the different course of disease and gastroesophageal reflux, the esophageal mucosa may have edema, congestion, erosion, ulcers, bleeding, stenosis and other pathological changes.
(2) grading of esophagitis under the microscope: grade 1, mucosal flushing without ulcer; grade 2, ring ulcer with proliferative tissue, easy to hemorrhage; grade 3, mucosal island left by ulcer formation; grade 4, esophageal stricture, It is also possible to directly measure the distance from the junction of the esophageal mucosa to the gastric mucosa to the esophageal hiatus, and the extent of mucosal damage.
(3) The formation process of the esophageal hiatus sliding sac in the mirror: According to Sun Yifang (2000), when the cardia tube is widened, the movement of the cardia is increased, the His angle morphology is obtuse or loose, and the size of the fundus cavity is dynamically changed. Adding the method of rapid insertion of the lens rod to induce nausea and vomiting, the whole process of esophageal hiatus sliding sputum formation can be seen under the microscope when the patient vomits. It is believed that the detection rate of slid esophageal hiatus hernia can be improved by this method. The whole process of the formation of the esophageal hiatus sliding sputum is roughly as follows:
1 At the beginning of the patient's vomiting action, the dentate line is first moved down by 1 to 1.5 cm due to the increase in the chest pressure of the breath.
2 The esophagus has a different degree of dilation in the esophagus within 3 cm proximal to the dentate line, and the ankle ring is opened and looped.
The 3His angle slides up against the small curved side until the two side walls are fully opened, and then protrudes into the esophagus.
4 The zigzag tube and the dentate line move, and the dentate line is buried under the ridge as the ridge increases, so its movement cannot be seen.
5 Finally, with the big curved side as the main turning-in, the four walls are driven, and then the squat continues to increase the upward movement, which can be shot on the mirror surface to form the intrusion process.
6 With the vomiting action stopped, the inhalation action appeared, and the sputum slideed back down the esophagus and returned to the stomach cavity.
5. Nuclide 99mTc scan
The radionuclide 99mTc scan can clearly display the image of the stomach, and the type of esophageal hiatus can be determined according to the shape change of the image of the stomach:
1 Esophageal fistula: The shape of the stomach changes in a dumbbell shape.
2 Esophageal hiatus sliding sputum: the disappearance of the stomach angle is conical, which can clearly show the reflux. According to Li Xinyuan et al, the shape of the esophageal hiatus slide is not obvious, but the diagnosis rate of gastroesophageal reflux is 100%. The shape of the esophageal sputum is a dumbbell-shaped change. The radionuclide 99mTc scan is not only important for the diagnosis of esophageal hiatal hernia and gastroesophageal reflux, but also can be used for continuous esophageal hiatus. The evaluation provides the basis.
6. Esophageal pressure measurement
The physiological pressure gauge was used to measure the length and pressure of the high pressure area in the lower end of the esophagus, the intragastric pressure, and the pressure difference between the two. The intragastric pressure of the disease was higher than the lower end of the esophagus, and the high pressure area of the lower end of the esophagus became shorter or disappeared. The pressure difference between the esophagus and the stomach was lower than that of the normal controls.
7. Determination of esophage pH
(1) Standard acid reflux test: the patient was placed in a supine position, the pH electrode was placed 5 cm above the upper boundary of the high pressure area under the esophagus, and a side hole of the pressure measuring catheter was placed in the stomach, and 0.1 mol/ was injected through the side hole. L concentration of diluted hydrochloric acid 300ml, the catheter was pulled out, and the pH value of the esophageal cavity was measured by the pH electrode to be greater than 5, so that the patient was in the supine position, the left lateral position, the right lateral position and the lower leg height 15 °, Deep inhalation in each different position, coughing, inhalation and suffocation after pinching the nose, which may cause reflux of the esophagus and stomach (increase intra-abdominal pressure, reduce intrathoracic negative pressure), and make the pH in the esophagus The value drops below 4.0 to induce esophageal reflux, and the degree of reflux is judged according to the number of reflux. In 16 chances of causing reflux, the normal person is no more than 4 times. The test is a semi-quantitative test. Assist in diagnosis.
(2) Dynamic monitoring of esophageal pH value 24h: Designed by Johnson and DeMeester (1974) and applied to clinical practice, it is regarded as the gold standard for diagnosing gastroesophageal reflux. It is the best quantitative method for monitoring the application of pH microelectrode. Portable recorder, drugs that change the esophageal pressure (muscle relaxant, anticholinergic drugs, nitrate drugs, calcium channel blockers) and drugs that reduce gastric acid secretion (antacids, 3 to 5 days before the examination) H2 receptor blocker), etc., according to the position of the lower esophageal high pressure area measured by esophageal kinetics, the pH electrode is positioned in the 5 cm esophageal lumen above the upper boundary, and the pH value of the place is continuously monitored. During the monitoring process, the subject's living activities strive to be close to the normal living conditions, can stand, walk or fall down, eat according to daily habits, but must not enter the diet with pH less than 5, monitoring the eating, sleeping, posture, vomiting, chest pain The start and end time is marked according to the note button on the recorder, and then the computer and software are used to analyze the monitoring results to understand the relationship between symptoms and acid reflux. After the monitoring, the pH monitor is connected with the computer. At the same time, the correct start and end time of the recorded conditions are input into the computer, analyzed and processed by software, and finally the pH monitoring pattern and analysis report are printed, from which the number of reflux can be known, and each reflux is greater than 5 min. The number of times, the longest reflux time, the total time of pH in the esophageal lumen is less than 4, the total time of pH less than 4 as a percentage of the total monitoring time, the relationship between body position and reflux, between symptoms and reflux Relationship, relationship between eating and reflux, and scoring the results according to the DeMeester scoring method, the normal value is <14.72.
Diagnosis
Diagnosis and differentiation of hiatus hernia
Diagnosis can be based on medical history, clinical symptoms, and laboratory tests.
Mainly rely on X-ray examination to confirm the diagnosis, routine chest fluoroscopy and chest radiographs pay attention to the presence of gas-filled cysts and gas-liquid planes on the back of the heart or on both sides of the heart shadow, and pay attention to the presence or absence of sac and sac in the swallowing examination. Gastric mucosa appeared inside and the appearance of the esophagus and stomach ring was observed. If one or more of the above signs appear in the barium meal examination, the diagnosis of the sliding type hiatus hernia can basically be established. Endoscopy can be used to exclude esophageal ulcers, inflammation, stenosis, and space-occupying lesions.
Differential diagnosis
Patients with esophageal hiatal hernia are unclear, pain is recurrent, the curative effect is poor and accompanied by a variety of other symptoms, causing anxiety, nervous emotions and multiple consultations in multiple departments. Due to various symptoms and changes, the diagnosis is diagnosed. There are reports of more than 30 diseases.
1. Chronic bronchitis, pulmonary infection
Some patients with hiatal hernia, especially in neonates or infants, may be inhaled into the trachea due to transesophageal reflux to the pharyngeal stomach, causing long-term chronic cough, cough, and even bronchial asthma attacks, often with repeated respiratory tracts. Infection for long-term medical treatment, misdiagnosed as chronic bronchitis, pneumonia, simple chronic bronchitis or pulmonary infection symptoms, signs and X-ray abnormal images are limited to the lungs, and this disease has symptoms other than respiratory symptoms, such as after meals Lower xiphoid pain, sternal pain, acid reflux, burning pain after sternal bones, difficulty in swallowing, etc. X-ray fluoroscopy, plain film examination can also be changed outside the lungs, upper gastrointestinal X-ray examination, gastroscopy, CT examination Help diagnosis and differential diagnosis.
2. Coronary heart disease
Adult esophageal hiatal hernia is similar to the onset age of coronary heart disease. The clinical symptoms of some patients are similar to the manifestations of angina pectoris. Therefore, misdiagnosis often occurs, or the disease is often missed when coexisting with coronary heart disease. According to He Qiuyu et al, 75 cases of esophageal hiatus hernia, including: lower sternum 46 patients (61.3%) had pain in the posterior and 29 patients (38.7%) had pain in the anterior region. Chest pain lasted for several minutes to more than 1 hour, mostly in 20-30 minutes; chest pain radiated to the upper chest, back, neck, left shoulder and left 32 cases (42.7%) of the arm; chest electrocardiogram and 24h dynamic electrocardiogram showed ST-segment depression, T-wave low-level inverted or arrhythmia, 9 cases of esophageal hiatal hernia complicated with coronary heart disease confirmed by further examination; The conventional electrocardiogram was normal, and the 24h dynamic electrocardiogram showed myocardial ischemic changes at the onset of chest pain, and there were neck, left shoulder, and left arm radiation pain, but the submaximal active plate test was negative in 6 cases; considering esophageal hiatus hernia X-ray or gastroscopy confirmed only 17 cases (22.7%), and the remaining 58 cases were diagnosed and/or misdiagnosed as 52 cases (69.3%) of coronary heart disease. The comprehensive literature, the reasons for misdiagnosis include:
1 The clinical manifestations of the two are similar. Esophagitis occurs in esophageal hiatus hernia, esophageal ulcer can induce esophageal spasm and post-sternal pain; sac sac moves, twists or larger esophageal fistula, vagus nerve around the sac or around the sac Stimulation, reflexively causing coronary insufficiency, electrocardiogram and 24h dynamic electrocardiogram showed myocardial ischemia-like changes; about 1/3 of patients with esophageal hiatal hernia showed paroxysmal pain, paroxysmal arrhythmia, chest tightness and precordial area The sense of beam, and the pain can be radiated to the back, neck, ear, left shoulder and left arm; its pathogenesis, pain, chest pain, duration of chest pain and nitroglycerin or isosorbide dinitrate They are similar to coronary heart disease and angina, and sometimes difficult to identify.
2 The age of onset is similar. Some scholars have reported that the incidence of this disease is less than 40% under 40 years old, 38% over 50 years old, and 69% over 70 years old. This age is also a good age for coronary heart disease, and it is clinically The incidence of coronary heart disease is much higher than that of esophageal hiatus. It is one of the most common diseases that cause rapid death in the elderly. Clinicians attach great importance to it. Therefore, in patients with esophageal hiatal hernia, if there is chest pain in the elderly, even if there is obvious The upper gastrointestinal symptoms are often first considered as cardiogenic chest pain, especially in people with diabetes, hypertension, and hyperlipidemia.
3 coexisting, neglecting the existence of esophageal hiatal hernia, as mentioned above, the age of the two are the same, so the coexistence of the two is also very common, because the symptoms of the two are similar, coronary heart disease is extremely common, so for When the same two diseases coexist in the same patient, the diagnosis of coronary heart disease is often considered and satisfied, leading to missed diagnosis of hiatal hernia.
4 neglected the relief effect of coronary artery dilatation drugs on non-cardiac chest pain, because nitroglycerin, isosorbide dinitrate (disgusting), calcium antagonist, nifedipine (heart pain) and other coronary artery expansion drugs can also be different To alleviate or relieve the esophageal smooth muscle and diaphragmatic spasm, reduce or relieve the pain of the posterior sternum, which is beneficial to the reduction and relief of the vagus nerve, thus blocking the reflex sputum of the coronary artery, plus the direct expansion of the coronary artery by the drug. Role, in the onset of chest pain in patients with esophageal hiatal hernia, after taking the above drugs, some patients may relieve or partially relieve the pain in the posterior sternum or the pain in the precordial area. Due to the lack of understanding of the anatomy and pathophysiological characteristics of the hiatus hernia, the ignorance The remission effect of coronary dilatation drugs on non-cardiac chest pain is satisfied with the diagnosis and "effective treatment" of coronary heart disease, which is one of the reasons for misdiagnosis of this disease as coronary heart disease or coexistence with coronary heart disease.
In summary, the chest pain of hiatal hernia is easily misdiagnosed as a coronary heart attack, but as long as the anatomy, pathology, pathophysiology and clinical features are mastered, the following points can be identified:
1 Although the conventional electrocardiogram and 24h dynamic electrocardiogram of the disease showed ST-segment depression, T-wave low-level inverted or arrhythmia, but the routine electrocardiogram of the chest pain interval was normal, the sub-maximal activity plate test was negative, and the patients with coronary heart disease were in the intermittent period of chest pain. The electrocardiogram also changed abnormally, and the submaximal activity plate test was positive.
2 patients with esophageal hiatal hernia have no significant relationship with fatigue, but close to the diet, often after 0.5 to 1.0h after a full meal, chest pain, supine, bent, cough, breath holding force or forced defecation and other factors of increased abdominal pressure Can induce or aggravate chest pain, but in semi-recumbent position, standing, walking, vomiting sour water or stomach contents, chest pain is relieved or relieved, chest pain occurs during sleep, and gradually relieves after sitting, and coronary heart disease angina has no such characteristics.
3X-ray examination may have a sacral sac, a gastric mucosa, a rise and contraction of the lower esophageal sphincter, and gastroesophageal reflux.
4 endoscopy can be seen: the dentate line shifts > 2cm, the narrow end of the esophagus is widened and straightened, the lower esophagus, the cardia, the corpus corpus is on the same longitudinal axis, the gastric juice flows back into the esophagus, and the gastric mucosa folds through the sputum. The esophageal hiatus is turned into the thoracic cavity, and the gastric mucosa such as walnut is invaded into the esophagus when the patient is nausea. The esophageal fistula is seen in the gastric mucosa. The cystic cavity is inhaled, exhaled and bulged, and the endoscopic appearance of reflux esophagitis. .
5 Coronary artery dilatation drugs such as nitroglycerin, isosorbide dinitrate (xinxintong) or nifedipine (xintongding) for patients without coronary heart disease, although some patients have relieved chest pain, but the effect is slow or the effect is not certain, while the application of West Mitidine (cimetidine), ranitidine, famotidine and gastric motility drugs (domiperone, cisapride, etc.) can significantly relieve symptoms such as chest pain and prolong the interval between the patients.
3. Cholecystitis, cholelithiasis
Esophageal hiatus hernia can be caused by xiphoid pain, sac and sputum contents sliding up and down the esophageal hiatus to stimulate the vagus nerve reflex caused by right upper quadrant pain, nausea and vomiting, misdiagnosis of cholecystitis, cholelithiasis, or both coexisting only in the gallbladder Inflammation, cholelithiasis diagnosis and missed diagnosis, but cholecystitis, cholelithiasis often have fever, jaundice, elevated blood picture, abnormal liver function, and B-ultrasound, CT examination showed biliary system inflammation, stone imaging, and simple esophageal hiatus hernia The patient had no jaundice, abnormal liver function and other changes, B-ultrasound, CT examination did not have inflammation of the hepatobiliary system, stone imaging.
When patients with symptoms of xiphoid pain, right upper quadrant pain, nausea and vomiting can not only think of hepatobiliary diseases, but also consider the possibility of esophageal hiatus hernia, as long as the disease is thought, upper gastrointestinal X-ray examination should be performed, such as You can see the sacral sac sac, the gastric mucosa appears on the sputum, the lower esophageal sphincter rises and contracts, gastroesophageal reflux and other signs can be diagnosed.
4. Gastrointestinal bleeding, anemia
Due to esophageal mucosal erosion ulcers or repeated intrusion into the gastric mucosa tear, sputum into the stomach ulcer, esophageal hiatus hernia may have gastrointestinal bleeding, the incidence of 2.5% to 20.7%, mostly as a small amount of black stool or a small amount of fresh blood In severe cases, a large amount of hematemesis, melena, severe anemia can also be the first symptom, often suspected as a clinically more common blood disease, digestive tract inflammation or ulceration, bleeding caused by digestive tract tumors, neglecting the existence of esophageal hiatus hernia Possibly, but as long as the gastrointestinal bleeding is encountered, the patient with anemia thinks of the disease, and the gastroscope is performed in time. The X-ray angiography of the digestive tract can be diagnosed.
5. Digestive diseases
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