mesenteric hiatal hernia
Introduction
Introduction to mesenteric hiatus hernia Mesenterichiatalhernia is caused by intestinal fistula through the mesenteric rupture. Rokitansky (1826) first discovered that the cecum broke into the ileum and the mesenteric rupture near the colon. Loebl (1844) reported the first case of the transverse mesenteric hernia, and Turel (1932) first reported a case of sigmoid mesenteric hiatal hernia. Marsh (1888) and Ackerman (1902) surgically treated patients with mesenteric hiatal hernia and succeeded. The disease is rare in clinical practice, mostly with intestinal obstruction as its main manifestation. Clinical data show that acute intestinal obstruction caused by mesenteric hiatal hernia accounts for about 1% to 2% of acute mechanical intestinal obstruction. Because of its sacless sac support, the intestines that break into the mesenteric hiatus are very prone to torsion, strangulation, necrosis and perforation, and severe cases can be life-threatening. Preoperative diagnosis is difficult. basic knowledge The proportion of illness: 0.002% Susceptible people: no specific people Mode of infection: non-infectious Complications: bloating, abdominal mass
Cause
Mesenteric hiatal hernia
(1) Causes of the disease
The small mesentery may sometimes have congenital defects or hiatus, and the transverse mesenteric may occasionally have defects. Small intestine fistula may pass through the hole for obstruction or incarceration. Intestinal intestinal ischemia may be related to congenital mesenteric defect. More common in infants with intestinal obstruction.
(two) pathogenesis
Studies have confirmed that the presence of mesenteric hiatus is the anatomical basis of the pathogenesis of internal hemorrhoids. Mitchell and Watson found 3 cases of ileocecal mesenteric holes in 1000 cases and 1600 cases, but no internal hemorrhoids occurred before birth, indicating that although many individuals have Mesenteric hiatus exists, but it does not necessarily form internal hemorrhoids. It can only occur under the influence of multiple factors such as peristalsis of bowel or abnormal peristalsis and increased intra-abdominal pressure.
1. There are abnormal hiatus on the mesentery of patients with abnormal mesenteric membrane. It is one of the important reasons for the occurrence of internal hemorrhoids. The cause of mesenteric hiatus can be congenital dysplasia, which can also be caused by trauma or surgical errors, among which congenital dysplasia accounts for The vast majority, especially in children, the author reported that 99 cases of mesenteric hiatal hernia, only 11 cases are acquired; another scholar reported that 83 cases of 83 cases of mesenteric hiatus hernia are congenital, Treves found the fetus The ileocecal mesenteric has a round or oval region (Treves region) characterized by no fat and visible blood vessels, and no branches of the mesenteric lymphatic vessels, which are high-risk areas of mesenteric defects.
(1) Congenital mesenteric dysplasia: The current understanding of the causes of congenital mesenteric hernia is still inconsistent.
1 It is believed that after the normal rotation of the embryonic intestine, the peritoneum of the visceral peritoneum and the peritoneal membrane merge into the mesentery. If the fusion is incomplete or the part of the dorsal mesenteric of the human body degenerates, the mesenteric leaves are left with a hole;
2 Others believe that it is caused by ischemic lesions in the mesentery of the fetus. For example, mesenteric hiatus occurs in the Treves area. This area is characterized by no fat and visible blood vessels. The formation of mesenteric hiatus is often accompanied by congenital intestinal malformation. Ischemia is an important cause of intestinal atresia or intestinal stenosis. For example, Murphy reported 11 cases of pediatric mesenteric hernia, 7 cases occurred in congenital intestinal atresia or mesenteric adjacent to the stenosis area, indicating insufficient blood supply and mesenteric rupture. Close relationship;
3 Some scholars believe that during the fetus, due to the decline of the cecum, the ileum mesin occurs quite rapidly;
4 Some scholars have speculated that when the two layers of epithelium are opposite, there is a lack of connective tissue matrix support in the middle, which is prone to gaps or defects and self-forming pores.
Anatomical and clinical data show that mesenteric hiatus can occur in the small mesentery, transverse mesenteric, sigmoid mesenteric, appendix, and omentum. Mesenteric hiatus is common in small mesenteric hiatus, especially in ileocecal mesenteric (Treves area) defects caused by the most common intra-abdominal fistula (Figure 1), accounting for about 53%, the mesenteric hiatus accounted for about 28% of the mesenteric hiatus, which is the most common mesenteric hiatus, transverse mesenteric tear. Occurred in the left aortic artery and the avascular zone of the transverse mesenteric root, so the transverse mesenteric hiatal hernia is good (Fig. 2), the sigmoid mesenteric defect may be ring-shaped, common in the lower part of the superior rectal artery, the appendix Mesangial defects and large omental hiatus are extremely rare.
The causes and locations of mesenteric hiatus are different, and the size of the hiatus is different. Congenital mesenteric hiatus is mostly single, and some scholars have reported that there may be more than 20 holes in a few cases, even into a sieve-like structure. Mostly round or elliptical, the edges are neat, smooth, hard and tough, no adhesion, and there is no fat blood vessels in the hole area. According to autopsy and clinical observation, the transverse mesenteric membrane is the largest due to congenital mesenteric dysplasia, and the sigmoid mesenteric membrane The hiatus is second, the small mesenteric hiatus is again, and the appendix mesenteric is the smallest.
Clinically occurring in the larger diameter of the mesenteric hiatus, it is not easy to occur in the intestinal incarceration, but occurs in the mesenteric hiatus of the small mesenteric, prone to intestinal incarceration, strangulation or necrosis, in addition to some patients with mesenteric hernia At the same time accompanied by congenital gastrointestinal dysplasia, such as poor intestinal rotation, intestinal atresia.
(2) Acquired mesenteric hiatus: The acquired factors that cause mesenteric hiatus are:
1 iatrogenic factors: such as the implementation of intestinal resection and intestinal anastomosis, choledochal jejunum Roux-en-y anastomosis and other operations, the unsealed mesentery or mesangial suture is not strict to form a fissure, under other incentives, the intestine can be invaded;
2 traumatic factors: closed abdominal trauma, can cause mesenteric tear to form a hole; open abdominal trauma, can directly damage the mesentery, if the operation is missing or repair is not strict, postoperative internal hemorrhoids;
3 infection factors: inflammation of the mesentery itself or around, can cause mesenteric defects, forming a hole.
The location of secondary mesenteric hiatal hernia is related to the formation of mesenteric hiatus. For example, iatrogenic mesenteric hiatal hernia is more in the surgical operation site; traumatic mesenteric hiatus is associated with other organ damage in the abdominal cavity, and there is a hematoma around the fresh traumatic hiatus. Or blood clots, old traumatic hiatus, there are obvious scar tissue, the edge of the hiatus is irregular, not neat; the location and size of the mesenteric defect caused by infection are related to the location of the infection, and some authors have encountered 1 case of gastric cancer. After reoperation with acute pancreatitis, it was found that the pancreatic juice was corroded and the infection caused a large area of the transverse mesenteric defect.
2. Intestinal peristalsis or abnormal bowel movements Under normal conditions, there is no pressure difference in the abdominal cavity. Because the mesentery is long, the intestine can enter the hiatus during natural peristalsis. After abnormal peristalsis or overeating, part of the intestinal tube gains or the body position suddenly changes. As well as the cause of increased intra-abdominal pressure, the intestines are more likely to slip into or protrude into the mesenteric ruptures to form internal hemorrhoids, resulting in incomplete or complete intestinal obstruction. The intestines that break into the mesenteric rupture can quit with the peristalsis, or repeatedly. Repeatedly, the patient may have intermittent episodes or chronic abdominal pain. The edge of the mesenteric orifice is locally edema, hyperplasia, and thus thickened due to repeated intrusion and withdrawal of the intestine.
3. Increased intra-abdominal pressure When the intra-abdominal pressure suddenly increases, more small intestines can be squeezed into the holes, and the holes are retracted after passive expansion, preventing the small intestine from reversing, causing clamping, causing abdominal cramps and abdominal pain reflexes. Abdominal muscle spasm, increased clamping, due to the lack of support of the hernia sac, the incarcerated intestine can quickly cause blood circulation disorders, the intestine can also be reversed due to abnormal peristalsis, the intestines expand due to accumulation of gas, effusion Further accelerates the ischemic and necrotic rate of the incarcerated intestine, due to the incarceration of the intestine and its mesenteric compression, obstruction of blood flow, intestinal wall and mesenteric edema, thickening, thickening of the intestine and mesentery further compression around the ankle ring The blood vessels (the free edge of the mesenteric hiatus) can cause ischemia and necrosis of the intestine segment of the corresponding mesangium, and the intestinal tube that is invaded does not even have a strangulation. If the treatment is not timely, the patient loses a lot of body fluid, the intestines swell, infection and Toxin absorption, toxic shock and respiratory circulatory dysfunction.
Prevention
Mesenteric hiatal hernia prevention
There is no effective preventive measure for this disease. Early detection and early diagnosis are the key to the prevention and treatment of this disease.
Complication
Mesenteric hiatal hernia complications Complications, abdominal distension, abdominal mass
According to Wiuiamson, the incidence of intestinal necrosis of mesenteric hiatal hernia is about 50%, which is characterized by asymmetric abdominal distension and tender abdominal mass, total abdominal tenderness, rebound tenderness and muscle tension, positive abdominal dullness, and abdominal puncture. Hemorrhagic exudate was taken, and severe symptoms of toxic shock occurred.
Symptom
Mesenteric hiatus symptoms common symptoms abdominal mass cold sweat pale pale constipation shock bloody exudate abdominal distension abdominal pain bowel nausea
The clinical symptoms and signs vary depending on the size of the mesenteric hiatus (ankle ring) and the size of the intestines that are invaded, whether or not complete intestinal obstruction occurs, and whether the strangulation occurs.
If there is no incarceration in the intestines, the clinical symptoms are more mild, but due to the repeated intrusion and withdrawal of the intestinal fistula, the mesenteric or intestinal tube is stimulated by traction, and some patients may exhibit intermittent seizures. Abdominal pain, or chronic abdominal pain, the pain is mostly in the upper abdomen or umbilical cord, a few with vomiting and constipation, most of the abdominal distension is not obvious, and lack of intestinal type, intestinal peristalsis and bowel sounds hyperthyroidism and other signs of mechanical intestinal obstruction.
Once the inguinal fistula is strangulated, the symptoms and signs of complete intestinal obstruction are clinically manifested as sudden upper abdominal or peri-umbilical persistent colic, paroxysmal aggravation, accompanied by nausea, vomiting, and cessation. Exhaust defecation, abdominal distension and other symptoms of strangulated intestinal obstruction, with the progress of the disease, due to a large number of fluid loss, infection and poisoning, patients with cold sweats, pale, and short-term acute diffuse peritonitis and toxic shock Some patients, such as invasive intestinal fistula, can occur, asymmetrical abdominal distension, and can touch the abdominal mass; full abdominal tenderness, rebound tenderness and muscle tension, abdominal movement dullness positive, abdominal puncture can draw hemorrhagic exudate .
In the internal iliac crest of the transverse mesenteric sac, the small intestine that penetrates the retinal sac can pass through the Winslow hole, the hepatic ligament and the rupture or weak area of the gastric collateral ligament and then return to the large abdominal cavity, because the intestinal segment "stroke" abnormally leads to the distal stomach. Under pressure, the patient may have symptoms similar to chronic ulcer disease or pyloric obstruction.
The vast majority of mesenteric hiatus hernia is difficult to confirm before surgery. It can only be diagnosed in surgical exploration. Some scholars have reported that a group of 99 patients with mesenteric hiatal hernia have not been diagnosed before surgery, such as preoperatively. Being alert enough and being able to pay attention to the following points may help to diagnose correctly.
Examine
Examination of mesenteric hiatus hernia
1. Hemoglobin and hematocrit can be increased due to lack of water and blood concentration.
2. When the white blood cell count and neutrophils are significantly elevated, it is suggested that intestinal narrowing occurs.
3. Serum electrolytes (K, Na, Cl-), blood gas analysis and other measurements can reflect the balance of water, electrolyte and acid-base.
4. Abdominal fluoroscopy or plain film can show the performance of strangulated intestinal obstruction, such as a large amount of effusion in the intestine, "intestinal obstruction", dense mass (false tumor), etc., but generally can not be clear Causes obstruction.
5. Superior mesenteric artery angiography Selective superior mesenteric artery angiography can indicate the abnormal direction of the mesenteric vessels through the ankle ring and blood circulation.
6. CT scan can show the location of the abdominal cavity, intestinal gas accumulation, effusion, intestinal wall thickening, intestinal tube mass shadow and so on.
Diagnosis
Diagnosis and differentiation of mesenteric hiatus hernia
Diagnostic criteria
History
(1) The patient has intermittent episodes of abdominal pain or chronic abdominal pain. The site is mostly in the upper abdomen or umbilical cord. A few are accompanied by vomiting and constipation. The abdominal distension is not obvious, and the symptoms and signs of typical mechanical intestinal obstruction are lacking.
(2) Sudden onset of symptoms and signs of acute complete intestinal obstruction on the basis of chronic abdominal pain, may have asymmetric abdominal distension, and can touch tender abdominal mass, such as total abdominal tenderness, rebound tenderness and muscle tension, Abdominal mobility dullness is positive, abdominal puncture can draw hemorrhagic exudate, indicating that the intestine has been strangulated or necrotic.
2. X-ray inspection
(1) If acute complete intestinal obstruction occurs, abdominal fluoroscopy or plain film can show effusion in the intestinal lumen, "intestinal obstruction", dense mass (false tumor) and so on.
(2) Selective superior mesenteric artery angiography and CT scan are helpful for diagnosis.
Differential diagnosis
The disease should be distinguished from adhesive intestinal obstruction, intestinal torsion, intussusception, mesenteric vascular embolization, perforation of gastroduodenal ulcer, acute necrotizing pancreatitis, acute appendicitis and other surgical acute abdomen.
