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CASE REPORTZeyad S Alharbi, M.DAn 18 years old male presented
with abdominal pain for 1 day and vomiting of blood for 2 days. The
pain started suddenly mainly in epigastrium .
Hematemesis 4 times per day of medium amount for 2 days with
dizziness no other GI symptoms.He is previously healthy and not
known to have any chronic diseases.
Patient reported a history of Blunt Abdominal trauma 5 months
earlier and recovered without and significant impairment.On
examination, he was unwell, with tachycardia 140/min and Resp Rate
of 22/min
Abdomen was soft with guarding and tenderness over the
epigastrium, positive bowel sound and no organomegally.
U/S of the abdomen was negative for free fluid and there was
fluid in left pleural space.
WBC:17.6 Hgb:14.2 Hct:43.9 Plt:340
Glu:126 Urea:28 Creat:1.1 Na:136 K:4.1 LDH:212 AST:55 ALT:80
T.bili: 1.82 D-bili:0.31 In-bili:1.51 Amyl:472
Chest X-ray of the patient
Repeated CBC showed a Hgb of 2.o
Patient was rushed to the operation room for a diagnostic
laparoscopy and possible laparotomy .
Intra-Operative Endoscopy reports gastric ulceration and
bleeding with stenotic opening just below the cardia
With laparoscopy there was strangulated hiatus hernia ( stomach
& omentum ) cannot be reduced laparoscopically and the
procedure was converted to laparotomy.
The stomach and omentum was reduced from mediastinum.
Finding of Gangrenous, not perforated, stomach and omentum from
the lower end of the esophagus till the antrum .
Gasterectomy with oesphegeo-jejenostomy and jejenojejenostomy
side to side anastmosis ( Roux-en-Y )done for the patient. The
patient was transferred to intensive care unit right
after.Histopathology reported Transmural hemorrhagic infarction of
the resected part and moderated chronic gastritis .His ICU course
was not complicated with acute or serious event and was extubated
in POD # 2 with a total stay of 7 days.
Patient been shifted to surgical floor with good and stable
condtion.
At the floor, patient recovered slowly and had low grade fever
on and off.
Upper GI gastrograffin done and showed intact and no leak at
anastmosis sites .
Patient had a spike of fever of 39 for two nights (POD#11 and
12) and CTscan of Abdomen and pelvis revealed no intra-abdominal or
pelvic collection.
Patient encouraged for more ambulation and incentive spirometer
use.
Patient been discharged in POD # 14 with pain free , tolerating
diet and stable vital signs.
Diaphragmatic Hernias
Bochdalek Hernia
Congenital hernia throughthe lumbocostal trigone.Can expand to
includealmost wholehemidiaphragm. Morecommon on left.
Sac present in 1015%.Contents: small intestine usual;stomach,
colon, spleen, frequent.Pancreas and liver rare. Liver only in
right-sided hernia.17Morgnani hernia and otherAnterior hernia
Congenital potential herniathrough muscular hiatuson either side
of thexiphoid process.Usually on the right;bilateral hernias
areknown. Actual herniationusually the result ofpostnatal
trauma
Sac present at first and Can rupture later, leaving no trace.
Contents: Infants: liver. Adults: omentum. Can be followed by colon
and stomachlater.18Peritoneopericardial hernia(defect of the
centraltendon, defect of thetransverse septum)Congenital hernia
throughcentral tendon andpericardium.Sac rarely present.Contents:
stomach,colon.
Hiatal HerniaThere are 3 types of hiatal hernias.
The sliding hernia or type I is the most common.
Type I Hiatal HerniaThe E-C junction moves through the hiatus to
the visceral mediastinum.
Increased abdominal pressure( pregnancy, obesity, or vomiting )
and vigorous esophageal contraction may contribute the development
of the hernia.
G-E reflux and esophagitis may occur due to loss of tone of the
LES
Type II Hiatal HerniaIt is uncommon.
The phrenoesophageal membrane is not weakened diffusely but
focally.
The gastric fundus protrudes through the hiatus.
Type III Hiatal HerniaIt is combined with type I and type
II.
It is frequently present when a type II hiatal hernia have been
present for many years.
SYMPTOMSMany type I and type II hernia have few or no
symptoms.
Bleeding results from gastritis and ulcer can induce IDA,
resulting in fatigue and exertional dyspnea. Postprandial
discomfort may occur. The substernal fullness is often mistaken
MIComplications Bleeding, incarceration, volvulus, obstruction,
strangulation and perforation.
Gastritis and ulceration have been seen. The ulcer are the
result of poor gastric emptying and torsion of the gastric
wall.
ContIf vovulus occurs, severe pain and pressure in the chest or
epigastic region.
Fever, hypovolemic shock will be present if volvulus progresses
and strangulation occurs. In this situation, mortality rate is
50%.
DIAGNOSISThe diagnosis is suspected first on the CXR.
The most common finding is retrocardiac bubble with or without
air-fluid level.
In a giant hiatal hernia, the herniated organ may be found in
the right thoracic cavity.
D.D: mediastinal cyst or abscess, dilated obstructed esophagus,
as end stage of achalasia.
ContThe barium study of the UGI confirms the diagnosis.
Endoscopy and esophageal function test can detect the function
of LES.
34THERAPYThere is no accepted medical treatment for hiatal
hernia.
Surgery is indicated to prevent complications.
In type II hernia, if gastric volvulus or obstruction is present
without toxic signs, NG decompression must be performed. The
surgery is scheduled. 35Operative ApproachesThe operation or
operative approach is controversial.The principles of operation is
reduction of the hernia, resection of the hernia sac and closure of
the defect.It is easy to do intrathoracic dissection via
thoracotomy.However, transthoracic reduction may lead to volvulus
of the gastric body. 36Operative ApproachesAbdominal approach is
also suggested.
Additional procedures can be done, such as gastrotomy, which
obviates the NG tube and decreases the risk of recurrent
volvulus.
Abdomional approach is difficult to do in type III hiatal hernia
with G-E reflux and a foreshortened esophagus.
Laparoscopic repair is also advocated.37Should a Antireflux
Procedure Be Induced?It is controversial.It is indicated in
patients with esophagitis by symptoms and endoscopy, with a
hypotensive LES( < 10 mmHg ) or positive 24-hour pH monitoring.
38Operative Technique: Conventional Abdominal ApproachIn type II
hernia, the E-C junction is still in the abdomen, bounded
posteriorly with a fibrous band. It is careful not to take down the
attachment.
Dissection is done on the lower 4 to 8 cm of the esophagus.
The repair is done with nonabsorbable O sutures.
39Operative Technique: Conventional Abdominal ApproachAntireflux
procedure is done when significant reflux esophagitis is
present.
A loose Nissen fundoplication is suggested by authors.
If no fundoplication is performed then the stomach can be fixed
by two methods: Hill suture plication and Stamm gastrostomy.
40Operative Technique: Conventional Abdominal ApproachHill suture
plication: 3 interrupted nonabsorbable sutures between lesser curve
of the stomach and preaortic fascia
Stamm gastrostomy: 2 functions 1. It eliminates the need of NG
tube. 2. It fixes the stomach to the abdominal wall and to prevent
volvulus.41Operative Technique: Laparoscopic Approach
42Operative Morbidity and MortalityThe operative mortality is
less than 0.5%.
If gasric volvulus occurs, the operative mortality is up to
14%.
Pulmonary complication may be seen in patients with aspiration
resulting from volvulus or obstruction.
Complication of gastric stasis may result from edema of the
released gastric segment. 43Operative Morbidity and Mortality Other
complications include gastric perforation, gastric bleeding,
slipped Nissen fundoplication, small bowel obstruction and
atelectasis.44RESULTSLong-term results are excellent.Simultaneous
antireflux procedure is ineffective prophylaxis against recurrent
herniation resultant G-E reflux.The long-term result after
laparoscopic repair is unknown. 2nd caseA 71 years old male been
presented in ER c/o Abdominal pain for 3 days .It was associated
with constipation for 4 days and vomiting for 1 day prior to
admission.
12 hours prior to admission ,patients abdomen became more
distended and pain increased.
There was a history of Appendectomy 30 years ago.On examination
he was a febrile ,tachy with 127/min and normotensive.
His abdomen was distended till costal margin with mild
tenderness and Rt irreducible inguinal hernia.PR was empty and
bowel sound was negative.
Wbc: 14.2 Hgb:16.3 Plt: 502
Glu:217 Urea:126 Creat:2.1 Na:138 K:4.1D/D ???!
Discussion!
48Thank You!
