Is the severity of gastroesophageal reflux dependent on hiatus hernia size?

AIM: To determine if the severity of gastroesophageal reflux disease is dependent on the size of a hiatus hernia. METHODS: Seventy-five patients with either a small(n = 25), medium(n = 25) or large(n = 25) hiatus hernia(assessed by high resolution esophageal manometry) were investigated using 24-h esophageal monitoring and a self-assessed symptom questionnaire. The questionnaire comprised the following items, each graded from 0 to 3 according to severity: heartburn; pharyngeal burning sensation; acid regurgitation; and chest pain. RESULTS: The percentage total reflux time was significantly longer in the group with hernia of 5 cm or more compared with the group with a hernia of < 3 cm(P < 0.002), and the group with a hernia of 3 to < 5 cm(P < 0.04). Pharyngeal burning sensation, heartburn and acid regurgitation were more common with large hernias than small hernias, but the frequency of chest pain was similar in all three hernia groups. CONCLUSION: Patients with a large hiatus hernia are more prone to have pathological gastroesophageal reflux and to have more acid symptoms than patients with a small hiatus hernia. However, it is unlikely that patients with an absence of acid symptoms will have pathological reflux regardless of hernia size.

Intestinal infarction by internal hernia in Petersen's space after laparoscopic gastric bypass

Intestinal occlusion by internal hernia is not a rare complication(0.2%-5%)after Laparoscopic Roux-en-Y-GBP(LGBP)with higher morbidity and mortality related to mesenteric vessels involvement.In our Center,from October 2009 to April 2013 we have had 17 pts treated for internal hernia on 412 LGBP(4.12%).Clinical case:28-year-old woman,operated of LGBP(BMI=49;comorbidity:diabetes mellitus and arthropathy)about 10mo before,was affected by recurrent abdominal pain with alvus alteration lasting for a week.After vomiting,she went to first aid Unit of a peripheric hospital where she made blood tests,RX and US of abdomen that resulted normal so she was discharged with flu like syndrome diagnosis.After 3 d the patient contacted our Center since her symptoms got worse and was hospitalized.Blood tests showed an alteration of hepatic enzymes and amylases.The abdominal computed tomography(CT)showed the presence of fluid in perisplenic,peri-hepatic areas and in pelvis and a"target like imagine"of"clustered ileal loops"with a superior mesenteric vein(SMV)thrombosis involving the Portal Vein.During the operation,we found a necrosis of80 cm of ileus(about 50 cm downstream the jejuno-jejunal anastomosis)due to an internal hernia through Petersen’s space causing a SMV thrombosis.The necrotic bowel was removed,the internal hernia was reduced and Petersen’space was sutured by not-absorbable running suture.An anticoagulant therapy was begun in the post-operative time and the patient was discharged after 28 d.Conclusions:The internal hernia diagnosis is rarely confirmed by preoperative exams and it is obtained in most cases by laparoscopy but the improvement of technologies and the discover of"new"CT signs interpretation can address to an early laparoscopic treatment for high suspicion cases.

False esophageal hiatus hernia caused by a foreign body: A fatal event

Foreign body ingestion is a common complaint in gastrointestinal clinics. It is usually not difficult to diagnose because most of the patients report a definitive history of accidental foreign body ingestion. However, in rare cases, patients do not have a clear history. Thus, the actual condition of the patient is difficult to diagnosis or is misdiagnosed; consequently, treatment is delayed or the wrong treatment is administered, respectively. This report describes a fatal case of esophageal perforation caused by an unknowingly ingested fishbone, which resulted in lower esophageal necrosis, chest cavity infection, posterior mediastinum fester, and significant upper gastrointestinal accumulation of blood. However, his clinical symptoms and imaging data are very similar with esophageal hiatal hernia. Unfortunately, because the patient was too late in consulting a physician, he finally died of chest infection and hemorrhage caused by thoracic aortic rupture. First, this case report underlines the importance of immediate consultation with a physician as soon as symptoms are experienced so as not to delay diagnosis and treatment, and thus avoid a fatal outcome. Second, diagnostic imaging should be performed in the early stage, without interference by clinical judgment. Third, when computed tomography reveals esophageal hiatus hernia with stomach incarceration, posterior mediastinal hematoma, and pneumatosis caused by esophageal, a foreign body should be suspected. Finally, medical professionals are responsible for making people aware of the danger of foreign body ingestion, especially among children, those who abuse alcohol, and those who wear dentures, particularly among the elderly, whose discriminability of foreign bodies is decreased, to avoid dire consequences.

Gastroesophageal reflux disease is an uncommon condition in Asia: evidence and possible explanations

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A substantial incidence of silent short segment endoscopically suspected esophageal metaplasia in an adult Japanese primary care practice

AIM: To determine the incidence and characteristics of endoscopically suspected esophageal metaplasia (ESEM) in a primary adult care institution. METHODS: Eight hundred and thirty two consecutive individuals (mean age, 67.6 years) undergoing upper gastrointestinal endoscopy between January 2009 and December 2010 were included in this study. The diagnosis of ESEM was based on the criteria proposed by the Japan Esophageal Society, and was classified as long segment ESEM (3 cm or more) or short segment ESEM (< 3cm). Short segment ESEM was further divided into circumferential and partial types. Age, gender, hiatus hernia, esophagitis, gastroesophageal reflux disease (GERD)-suggested symptoms, and antacid medications were recorded as background factors. Esophagitis was graded according to the Los Angeles classification. Hiatus hernia was divided into absent and at least partially present. RESULTS: Long and short segment ESEM were found in 0 and 184 (22.1%) patients, respectively (mean age of short segment ESEM patients, 68.3 years). Male gender and hiatus hernia were shown to be significant factors affecting short segment ESEM by both univariate (P = 0.03 and P = 9.9x10-18) and multivariate [Odds ratio (OR) = 1.45; P = 0.04, and OR = 43.3; P = 1.5x10-7)] analyses. Two thirds of patients with short segment ESEM did not have GERD-suggested symptoms. There was no correlation between short segment ESEM and GERD-suggested symptoms. CONCLUSION: The incidence of short segment ESEM in our community practice seems higher than assumed in Asian countries. As GERD-suggested symptoms are a poor predictor of ESEM, endoscopists should bear in mind that silent short segment ESEM does exist and, in fact, was found in the majority of our patients.

Trajectories of endoscopic Barrett esophagus: Chronological changes in a community-based cohort

AIM To elucidate longitudinal changes of an endoscopic Barrett esophagus(BE), especially of short segment endoscopic BE(SSBE). METHODS This study comprised 779 patients who underwent two or more endoscopies between January 2009 and December 2015. The intervals between the first and the last endoscopy were at least 6 mo. The diagnosis of endoscopic BE was based on the criteria proposed by the Japan Esophageal Society and was classified as long segment(LSBE) and SSBE, the latter being further divided into partial and circumferential types. The potential background factors that were deemed to affect BE change included age, gender, antacid therapy use, gastroesophageal reflux disease-suggested symptoms, esophagitis, and hiatus hernia. Time trends of a new appearance and complete regression were investigated by Kaplan-Meier curves. The factors that may affect appearance and complete regression were investigated by χ~2 and Student-t tests, and multivariable Cox regression analysis. RESULTS Incidences of SSBE and LSBE were respectively 21.7% and 0%, with a mean age of 68 years. Complete regression of SSBE was observed in 61.5% of initial SSBE patients, while 12.1% of initially disease free patients experienced an appearance of SSBE. Complete regressions and appearances of BE occurred constantly over time, accounting for 80% and 17% of 5-year cumulative rates. No LSBE development from SSBE was observed. A hiatus hernia was the only significant factor that facilitated BE development(P = 0.03) or hampered(P = 0.007) BE regression. CONCLUSION Both appearances and complete regressions of SSBE occurred over time. A hiatus hernia was the only significant factor affecting the BE story.

Clinical application of tentorium cerebelli hiatus incision in treatment of severe and most severe brain injuries

Objective:: To explore the role of tentorium cerebelli hiatus incision in treating severe and most severe brain injuries complicated by tentorial herniation. Methods: From July 1994 to July 1999 tentorium cerebelli hiatus incision was done based on intracranial hematoma evacuation and bone flap craniectomy decompression in 70 cases of severe and most severe brain injuries complicated by tentorial herniation. Results: Of the 70 cases, GCS 3-5 was in 23 and GCS 6-8 in 47; satisfactory recovery in 39 cases ( 55.7 %), moderate disability in 12 ( 17.1 %), severe deficit in 6 ( 8.6 %), vegetative survival in 4 ( 5.7 %) and 8 ( 11.4 %) died. Conclusions: Tentoriun cerebelli incision is helpful in alleviating secondary brain stem injury from tentorial herniation and in reducing the disability and death rate of the patients.