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Morningmeeting◼Present：王又德醫師◼Supervisor：楊浚銘醫師1Introduction◼Bowelobstruction,gastroenteritis◼Severepai

n,especiallyvisceralpain◼Severesystemicillness(myocardialinfarction,sepsis,orshock)◼Pregnancy(hormones)◼Increasedintracranialpressure(centralmechani

sm)◼Chemotherapy(chemoreceptortriggerzone).23History◼Content◼Time◼Associatedsymptoms(fever,headache,abdominalpain..)◼Socialhist

ory(drugoralcoholabuse)◼Pastmedicalhistory(anyGIdisease,surgery)◼Medicationlist456Complication◼Hypovolem

ia◼Metabolicalkalosis◼Hypokalemia◼Mallory-Weisstearstypicallyfollowaforcefulboutofretchingandvomiting.Thelesionitselfisa1-to4-cmtearthrou

ghthemucosaandsubmucosa;◼Boerhaave'ssyndrome–--perforationofalllayersoftheesophagus--freepassageofesophage

alcontentsintothemediastinumandthorax--80%ofcasesinvolvetheposterolateralaspectofthedistalesophagus--surgicalemergency.--Mortalityi

s50%ifsurgeryisnotperformedwithin24hours◼Aspirationofgastriccontents78Hiatalhernia9Introduction◼Frequentfindingbyradiologistsand

gastroenterologists.10TypeI:Slidinghernia◼95%ofcases.◼Wideningofthemuscularhiataltunnelandcircumferentiallaxityofthephrenoesophagealmembrane→gast

riccardiatoherniateupward.◼Thephrenoesophagealmembraneremainsintact◼Posteriormediastinum111213TypeI:Slidingherni

a◼Mostsmallhiatalherniasareasymptomaticand,evenwithlargertypeIhernias◼Clinicalimplicationisthepropensitytodevelopgastroesophagealref

luxdisease(GERD).◼Thelikelihoodofsymptomaticgastroesophagealrefluxincreaseswiththesizeofthehiatalhernia.14Other

typesofhiatalhernia◼Lesscommontypesofhiatalhernia,typesII,III,andIV,arevarietiesof"paraesophageal"hernias→upto5%ofallhiatal

hernias◼Surgicaldissectionofthehiatusasoccursduringantirefluxprocedures,esophagomyotomy,orpartialgastrectomy.15TypeIIhernia◼Defec

tinthephrenoesophagealmembrane◼Gastroesophagealjunctionremainsfixedtothepreaorticfasciaandthemedianarcuateligament.◼Gastr

icfundusservesastheleadingpointofherniation1617TypeIIIhernias◼BothtypesIandII.18TypeIVhiatushernia◼Largedefectinthephrenoesop

hagealmembrane◼Allowingotherorgans,suchasthecolon,spleen,pancreas,andsmallintestine,toentertheherniasac.19Symptoms◼Epig

astricorsubsternalpain◼Postprandialfullness,substernalfullness,◼Nausea,andretching.20Complication◼Gastricvolvulus→dysphagia

◼Postcibalpain→gastrictorsion.◼Withintheincarceratedherniapouch→gastriculceration,gastritis,orerosions→Bleeding◼Respiratorycomplica

tionsresultfrommechanicalcompressionofthelungbyalargeherniaorotherorgansherniatingthroughthehiatus.21Treatment◼Headofbedelevation◼Die

tarymodification◼Refrainingfromassumingasupinepositionaftermealsandavoidanceofmealsbeforebedtime◼Avoida

nceoftightfittinggarments◼Obesityisariskfactor◼Restrictionofalcoholuse22Medicaltreatment◼Antacids◼H2blocker◼PPI◼Prokineticdrugs23Surgicaltreatment◼Re

ductionoftheherniatedstomachintotheabdomen◼Herniotomy(excisionoftheherniasac)◼Herniorraphy(closureofthehiataldefect)◼Anantiref

luxprocedure◼Gastropexy(attachmentofthestomachsubdiaphragmaticallytopreventreherniation)24Thanksalot◼References

fromUptodate25