2. History:
cc: 54 year old AA female presents to the
FCC for f/u after routine physical exam
for employment revealed patient to be
severely anemic (H/H was ).
HPI: At f/u visit she c/o weakness and
fatigue x 2 weeks. She also states that she
has been having dark stools for past 1-2
weeks.
3. History:
PMHx: PUD, UGI bleed, HTN,
Hyperparathyroidism, Fibroids.
PSHx: Hysterectomy
* The patient is well known to the FCC and is known
to be non-compliant.
4. History:
Meds: Patient currently taking no
medications.
Allergies: Shellfish (Iodine)
Patient denies any significant social or
family history.
5. Physical Exam in ED:
Vitals: T: 98.1 P: 90 R: 16 BP: 115/80
Exam:
Gen: AOx3, NAD.
CV: HRRR no m/g/r
Pulm: LCTAB no w/r/r
Abd: S/ND/NTTP +BS no g/r
Ext: no edema, 2/4 pulses Bilat. U/L extremeties
Rectal: good tone, guaic +
6. Labs:
CBC: WBC: 5.5 Hgb: 7.2 Hct: 24.1 Plt: 327
MCV: 63.3
BMP: Na 140
K 3.9
Cl 109
CO2 25
BUN 8
Cre 0.7
Glu 100
Ca 10.5
7. Tests:
EKG: NSR HR: 80bpm
U/A: negative
CXR: Hiatal hernia. Otherwise, NAD
AXR: No evidence of obstruction. Unremarkable
8. CT Abd/Pelvis:
* test performed with PO contrast only; IV contrast not used
secondary to pt’s iodine allergy
• Hiatal hernia with possible wall thickening
• 3.5-4.0cm hepatic cyst
• Prominence of the lest kidney cortex and
slight lobularity noted. Probable left renal
cyst
• Thickening of the splenic flexure
9. EGD:
• 10-12cm hiatal hernia
• Stomach appeared normal, no lesions
• Duodenum appeared normal, no lesions
• Biopsies obtained
Pathology:
• Descending duodenum: no inflammation, villous
architechure preserved.
• Antrum: mild chronic antral gastritis. No H. Pylori like
organisms seen.
• Distal esophogus: squamous mucosa with reactive
changes. No columnar epithelium is seen.
10. Colonoscopy:
• Annular mass at 45cm
• Mass nearly obstructing
• Unable to advance scope further
• Biopsies obtained
Pathology:
• Biopsy of mass at 45cm: moderately
differentiated infiltrating adenocarcinoma arising in
adenoma.
12. Plan:
• Admission to the FTS service
• IVF: D5NS @ 100cc/hr
• NPO
• NGT refused in ED
• Protonix bolus of 80mg then gtt @ 8mg/hr
• Transfusion of 2u PRBC
• GI consultation - EGD and colonoscopy
13. IncidenceIncidence
·True incidence difficult to determine because the
absence of symptoms.
·Sliding hernia (Type I) is the most common type.
·Type I is 7x greater than that of paraesophageal
hernias (Type II).
·Mixed paraesophageal hernias (Type III) are more
common than Type II but less so than Type I.
·Women 4:1
14. Type I - Sliding Hiatus HerniaType I - Sliding Hiatus Hernia
The gastroesophageal junction "slides" into the mediastinum, pulling
the stomach behind it.
15. Etiology - Sliding Hernia (Type I)Etiology - Sliding Hernia (Type I)
·Structural deterioration and weakening of the
phreno-esophageal membrane over time.
·Upper fascial layer (endothoracic) thins and lower
fascial layer (tranversalis) loses its elasticity.
·Persistent intra-abdominal pressure and the tug of
esophageal shortening on swallowing continually
stress the membrane.
·Over time, this causes weakening and yields to
cranial stretching.
17. Type II - Paraesophageal HerniaType II - Paraesophageal Hernia
"true paraesophageal" hernia. The gastroesophageal junction resides in
the abdomen, and a portion of the gastric fundus slides into the
mediastinum adjacent to the esophagus.
18. Type III - Mixed Paraesophageal HerniaType III - Mixed Paraesophageal Hernia
"mixed paraesophageal" hernia. The stomach and the
gastroesophageal junction are in the mediastinum.
19. Etiology - Paraesophageal HerniasEtiology - Paraesophageal Hernias
(Types II and III)(Types II and III)
·Develops when there is a defect, most often
congenital, in the esophageal hiatus.
·The cardia of the stomach is normally fixated
posteriorly by the pre-aortic fascia and the median
arcuate ligament. Other points of fixation also
include the gastrosplenic attachments.
·Loss of these fixation points is the major
determining factor between a Type I and Type II
hiatus hernia.
·When a larger anterior defect occurs in association
20. Type IV Paraesophageal HerniaType IV Paraesophageal Hernia
·Occurs when other abdominal viscera are also
present in the defect.
·Most commonly the omentum, transverse colon,
and small bowel.
·More often present emergently and associated with
more severe consequences.
·Complications include: strangulation, volvulus,
and obstruction.
21. Clinical PresentationClinical Presentation
·Many are asymptomatic. Especially Type I.
·Type IV presents emergently secondary to previously
mentioned complications in up to 50% of cases.
·Most common presenting symtoms:
·Early satiety
·Post-prandial bloating and/or pain
·Dysphagia
·Heartburn (GE Reflux symptoms)
·Weight loss
·Weakness / fatigue (Iron deficiency anemia - Cameron’s Ulcers)
22. DiagnosisDiagnosis
·History and Physical Exam.
·Laboratory Studies (CBC).
·Radiographic Studies:
·Upright PA and Lateral CXR
·UGI Series
·CT Chest and Abdomen
·Endoscopy.
·Manometry
23. C. Lateral XR of a type III (combined sliding-rolling or mixed) hernia.
24. Treatment - MedicalTreatment - Medical
·Since most patients are asymptomatic and the hernia is found
incidentally, ‘watchful waiting’ has been advocated recently.
·In a study using a Markov Monte Carlo analysis, Stylopoulos and
colleagues estimated that patients undergoing a strategy of ‘watchful
waiting’ would develop acute symptoms requiring surgery at a rate of 1.1%
per year. Using this estimate, they projected that less than 20% or patients
would benefit from elective repair of asymptomatic or minimally
symptomatic paraesophageal hernias.
·Majority of hiatus hernias are diagnosed in the elderly
population with multiple co-morbidities.
·Mortality from surgical repair reported to be apx 1-2%.
25. Treatment - SurgicalTreatment - Surgical
·Three surgical options:
·Thoracic approach
·Abdominal approach
·Laparoscopic approach
·Indications:
·Persistent, intractable, and refractory symptoms
·Complications (obstruction, bleeding, incarceration/strangulation)
·‘Giant’ hiatus hernia (greater than 50% of the stomach above the
diaphragm)
·Type IV hernia
·Regardless of approach, the main goals are the same:
·Reduction of hernia contents
·Excision of the hernia sac
26. Thoracic ApproachThoracic Approach
·The major advantage is the ability for direct mobilization of
the intra-thoracic esophagus.
·Allows for the option to perform a gastroplasty.
·These techniques are beneficial in often achieving an adequate
repair in the presence of a shortened esophogus.
27. Abdominal ApproachAbdominal Approach
·The major advantage is the ability to efficiently reduce the
hernia contents and ‘re-construct’ the intra-abdominal
anatomy.
·Allows for easy sac excision and adequate tension-free closure
of the crural defect.
·Avoids the need for single lung ventilation.
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37. Laparoscopic ApproachLaparoscopic Approach
·Rapidly gaining favor.
·Allows for better visualization of the hiatus and mediastinum.
·Other major advantages similar to other laparoscopic
procedures:
·Smaller incisions
·Less pain
·Quicker recovery times
·Shorter hospital stays
38. Laparoscopic ApproachLaparoscopic Approach
·Critics claim significantly higher recurrence rates.
·Several studies show as high as 40% (as compared to 12-15% for open
surgery).
·Proponents of laparoscopy argue these recurrences are sub-clinical
(up to 75% being asymptomatic and being identified only
radiographically)
·Steep learning curve. Therefore, prudent judgement must be
used in patient selection (in relation to one’s fair assessment of
their surgical ability).
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55. ResultsResults
Most outcome studies report relief of symptoms following surgical repair of
paraesophageal hernias in over 90% of patients. The current literature
suggests that laparoscopic repair of a paraesophageal hiatal hernia can be
successful. Most authors report symptomatic improvement in 80 to 90% of
patients, and less than 10 to 15% prevalence of recurrent hernia. However,
the problem of recurrent hernia following laparoscopic repair of any hiatal
hernia is becoming increasingly appreciated. Recurrent hernia is now the
most common cause of anatomic failure following laparoscopic Nissen
fundoplication done for GERD. The problem of recurrent hernia following
repair of large type III hiatal hernias has received less attention. Outcome
following repair of these hernias is usually based on symptomatic
assessment alone. Although recurrence rates of 6 to 13% have been
reported, they have largely been based on the need for reoperation or
investigations that are performed on a selective basis. Recent reports have
shown some degree of anatomic recurrence in up to 45% of patients who
underwent laparoscopic repair of their hernia.
56. ResultsResults
The principles of laparoscopic repair of a large intrathoracic hernia are
analogous to those for an open procedure, namely reduction of the hernia,
excision of the peritoneal sac, crural repair, and fundoplication. However,
there are several factors that make the laparoscopic repair of these large
hernias complex. First, volvulus of the stomach often is associated with
these hernias and makes identification of the anatomy, in particular the
location of the esophagus, difficult. Second, type III hernias tend to be large,
and the laparoscopic dissection of a large hernia sac frequently results in
bleeding sufficient to obscure the field of view and impair the recognition of
the anatomy. Third, the hiatal opening in a patient with a large hernia is
wide, with the right and left muscular crura often separated by 4 cm or
more. This can make closure problematic due to the tension required to
bring the crura together. Fourth, the right crus may be devoid of stout
tissue and sutures may pull through it easily. Finally, redundant tissue
present at the gastroesophageal junction following dissection of the sac
retards the creation of the fundoplication.
57. ResultsResults
The use of prosthetic mesh as an adjunct to repair has been advocated for
both open and laparoscopic repair of large hiatal hernias. Whether its use is
beneficial or not remains controversial, but most prefer to avoid prosthetic
material if possible. In contrast to groin hernias, the esophageal hiatus is a
dynamic area with constant movement of the diaphragm, esophagus,
stomach, and pericardium. Erosion of prosthetic material placed in this
area into the gastrointestinal tract will occur, the only question is how often.
The short-term follow-up of most studies is insufficient to provide insight
into this problem.
