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

emicillness(myocardialinfarction,sepsis,orshock)◼Pregnancy(hormones)◼Increasedintracranialpressure(centralmechanism)◼Chemotherap

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

ory(drugoralcoholabuse)◼Pastmedicalhistory(anyGIdisease,surgery)◼Medicationlist456Complication◼Hypovolemia◼Metabolicalkalo

sis◼Hypokalemia◼Mallory-Weisstearstypicallyfollowaforcefulboutofretchingandvomiting.Thelesionitselfisa1-to4-cmtearthroughthemucosaandsubmucosa;◼

Boerhaave'ssyndrome–--perforationofalllayersoftheesophagus--freepassageofesophagealcontentsintothemedia

stinumandthorax--80%ofcasesinvolvetheposterolateralaspectofthedistalesophagus--surgicalemergency.--Mortalityis50%ifsurgeryisnotperformedwi

thin24hours◼Aspirationofgastriccontents78Hiatalhernia9Introduction◼Frequentfindingbyradiologistsandgastroenterologists.10TypeI:Slidi

nghernia◼95%ofcases.◼Wideningofthemuscularhiataltunnelandcircumferentiallaxityofthephrenoesophagealmembrane→gastriccar

diatoherniateupward.◼Thephrenoesophagealmembraneremainsintact◼Posteriormediastinum111213TypeI:Slidinghernia◼Most

smallhiatalherniasareasymptomaticand,evenwithlargertypeIhernias◼Clinicalimplicationisthepropensitytodevelopgastroesophagealre

fluxdisease(GERD).◼Thelikelihoodofsymptomaticgastroesophagealrefluxincreaseswiththesizeofthehiatalhernia.14Othertypesofhiatalherni

a◼Lesscommontypesofhiatalhernia,typesII,III,andIV,arevarietiesof"paraesophageal"hernias→upto5%ofallhiatalhernias◼

Surgicaldissectionofthehiatusasoccursduringantirefluxprocedures,esophagomyotomy,orpartialgastrectomy.15Typ

eIIhernia◼Defectinthephrenoesophagealmembrane◼Gastroesophagealjunctionremainsfixedtothepreaorticfasciaandthemedianarcuateli

gament.◼Gastricfundusservesastheleadingpointofherniation1617TypeIIIhernias◼BothtypesIandII.18TypeIVhiatushernia◼Largedefectinthephrenoesopha

gealmembrane◼Allowingotherorgans,suchasthecolon,spleen,pancreas,andsmallintestine,toentertheherniasac.19Symptoms◼Epigast

ricorsubsternalpain◼Postprandialfullness,substernalfullness,◼Nausea,andretching.20Complication◼Gastricvolvulus→dysphagia◼Postcibalpain→gastr

ictorsion.◼Withintheincarceratedherniapouch→gastriculceration,gastritis,orerosions→Bleeding◼Respiratorycompli

cationsresultfrommechanicalcompressionofthelungbyalargeherniaorotherorgansherniatingthroughthehiatus.21Treatment◼Headofbedelevation◼Diet

arymodification◼Refrainingfromassumingasupinepositionaftermealsandavoidanceofmealsbeforebedtime◼Avoi

danceoftightfittinggarments◼Obesityisariskfactor◼Restrictionofalcoholuse22Medicaltreatment◼Antacids◼H2blocker◼PPI◼Pro

kineticdrugs23Surgicaltreatment◼Reductionoftheherniatedstomachintotheabdomen◼Herniotomy(excisionoftheherniasac)◼Herniorraphy(cl

osureofthehiataldefect)◼Anantirefluxprocedure◼Gastropexy(attachmentofthestomachsubdiaphragmaticallytopreventreh

erniation)24Thanksalot◼ReferencesfromUptodate25