1、Morning meetingnPresent：王又德醫師nSupervisor：楊浚銘醫師1IntroductionnBowel obstruction,gastroenteritis nSevere pain,especially visceral painnSevere systemic illness (myocardial infarction,sepsis,or shock)nPregnancy(hormones)nIncreased intracranial pressure(central mechanism)nChemotherapy(chemoreceptor trigge
2、r zone).23HistorynContentnTimenAssociated symptoms (fever,headache,abdominal pain.)nSocial history(drug or alcohol abuse)nPast medical history(any GI disease,surgery)nMedication list 456ComplicationnHypovolemia nMetabolic alkalosis nHypokalemia nMallory-Weiss tears typically follow a forceful bout o
3、f retching and vomiting.The lesion itself is a 1-to 4-cm tear through the mucosa and submucosa;nBoerhaaves syndrome -perforation of all layers of the esophagus -free passage of esophageal contents into the mediastinum and thorax -80%of cases involve the posterolateral aspect of the distal esophagus
4、-surgical emergency.-Mortality is 50%if surgery is not performed within 24 hoursnAspiration of gastric contents78Hiatal hernia9Introduction nFrequent finding by radiologists and gastroenterologists.10Type I:Sliding hernia n95%of cases.nWidening of the muscular hiatal tunnel and circumferential laxit
5、y of the phrenoesophageal membrane gastric cardia to herniate upward.nThe phrenoesophageal membrane remains intact nPosterior mediastinum 111213Type I:Sliding hernianMost small hiatal hernias are asymptomatic and,even with larger type I herniasnClinical implication is the propensity to develop gastr
6、oesophageal reflux disease(GERD).nThe likelihood of symptomatic gastroesophageal reflux increases with the size of the hiatal hernia.14Other types of hiatal hernianLess common types of hiatal hernia,types II,III,and IV,are varieties of paraesophageal hernias up to 5%of all hiatal hernias nSurgical d
7、issection of the hiatus as occurs during antireflux procedures,esophagomyotomy,or partial gastrectomy.15Type II hernia nDefect in the phrenoesophageal membranenGastroesophageal junction remains fixed to the preaortic fascia and the median arcuate ligament.nGastric fundus serves as the leading point
8、of herniation1617Type III herniasnBoth types I and II.18Type IV hiatus hernianLarge defect in the phrenoesophageal membranenAllowing other organs,such as the colon,spleen,pancreas,and small intestine,to enter the hernia sac.19SymptomsnEpigastric or substernal painnPostprandial fullness,substernal fu
9、llness,nNausea,and retching.20ComplicationnGastric volvulus dysphagianPostcibal pain gastric torsion.nWithin the incarcerated hernia pouch gastric ulceration,gastritis,or erosions BleedingnRespiratory complications result from mechanical compression of the lung by a large hernia or other organs hern
10、iating through the hiatus.21TreatmentnHead of bed elevation nDietary modificationnRefraining from assuming a supine position after meals and avoidance of meals before bedtimenAvoidance of tight fitting garments nObesity is a risk factor nRestriction of alcohol use 22Medical treatmentnAntacidsnH2 blo
11、ckernPPInProkinetic drugs23Surgical treatmentnReduction of the herniated stomach into the abdomen nHerniotomy(excision of the hernia sac)nHerniorraphy(closure of the hiatal defect)nAn antireflux procedure nGastropexy(attachment of the stomach subdiaphragmatically to prevent reherniation)24Thanks a lotnReferences from Uptodate 25
