Hiatal hernia in the elderly

Introduction to esophageal hiatus hernia in the elderly Hiatushernia refers to a disease in which part of the gastric sac enters the chest through the hiatus of the esophagus. Clinically, there may be symptoms such as pain, vomiting, and even bleeding. basic knowledge The proportion of illness: 0.001% Susceptible people: the elderly Mode of infection: non-infectious Complications: acute gastric dilatation, peptic ulcer, upper gastrointestinal bleeding in the elderly

Esophageal hiatal hernia

(1) Causes of the disease

The lower esophagus is surrounded by the esophageal membrane. The esophageal membrane is an elastic fiber membrane connecting the lower esophagus and the esophageal hiatus. In addition, the lower esophagus and esophagogastric junction are respectively fixed by the upper and lower esophageal ligament and the gastric ligament ligament. The esophageal hiatus is to maintain its normal position to prevent the esophagogastric junction and other abdominal organs from entering the thoracic cavity. The existence of the above normal anatomical structure is the basic condition for ensuring the relative fixation of the esophagogastric junction and the esophageal hiatus, resulting in esophageal hiatus. There are two causes of sputum, and these two reasons must be established to form esophageal hiatus hernia.

1. Esophageal hiatus relaxation and widening

The diameter of the normal foraging hole is 2.5cm. With the increase of age, the tissue around the hiatus and the esophageal membrane elastic atrophy, the esophageal hiatus is widened, the esophageal membrane and the esophageal ligament are relaxed, and the lower esophageal section and the cardia are gradually lost. The role of the normal position, once the hiatus is widened, the esophageal ligament becomes longer, and the esophagus can move up and down, the fissure becomes a weak link, similar to the formation of the esophagus, which is prone to paralysis.

2. Increased intra-abdominal pressure

Increased abdominal pressure, imbalance of chest and abdominal pressure is another pathogenesis factor, such as obesity, chronic cough, chronic constipation, ascites, late pregnancy, tight belt, frequent hiccups, huge intra-abdominal tumors, etc. can cause abdominal pressure increase, The tissue of the esophagus, the fundus, and the large omentum of the esophagus is pushed toward the widened and loose cleft palate, and is inserted into the thoracic cavity.

The etiology of this disease mainly includes congenital and acquired. The latter is more common. Congenital due to hypoplasia, the esophageal hiatus is looser than normal. The acquired sinus is associated with the esophageal membrane and the ligament around the esophagus. The widening of the hiatus and the increase of intra-abdominal pressure are related to the elderly. With the increase of age, the esophageal membrane elastic tissue shrinks, and the surrounding ligaments are prone to relaxation; and in the causes of increased intra-abdominal pressure, such as obesity, chronic Constipation, chronic cough, etc. are more common in the elderly, the elderly have the above two basic conditions, so they are more prone to esophageal hiatal hernia, in addition, esophagitis, esophageal ulcer caused by esophageal scar contraction; esophagus caused by tumor infiltration Shortening; thoracic kyphosis; strong vagus nerve stimulation caused by contraction of the esophageal longitudinal muscles and shortening of the esophagus, etc., can lead to traction in the thoracic esophagus and lead to the disease, severe chest and abdomen injury and surgery caused by esophagus, stomach and The change in the normal position of the esophageal hiatus or the relaxation of the esophageal membrane and the esophageal hiatus due to surgical traction can also cause the disease.

(two) pathogenesis

Esophageal hiatus can be divided into 3 types according to morphological classification.

Sliding type

Because of the relaxation of the hiatus of the esophagus, the ligaments around the esophageal membrane and the esophagus are loose, so that the esophageal section of the inferior esophagus and the esophageal hiatus of the esophagus slide into and out of the thoracic cavity, and the normal esophageal-gastric junction acute angle (His angle) becomes The obtuse angle causes the normal anti-reflux mechanism of the lower esophagus to be destroyed. Therefore, this type is complicated by different degrees of gastroesophageal reflux. This type is most common in clinical practice, accounting for 85% to 90%. Generally, the hole is small, and it appears on the back. It disappears when standing.

2. Esophageal hiatus hernia

Because the hiatus of the esophageal sac is thinned in the left anterior border, the esophageal hiatus is wide, part of the corpus (large bend) and the fundus are inserted into the thoracic cavity from the left side of the esophagus; while the esophageal membrane has not been destroyed, the gastroesophageal junction is still under the armpit The underarm esophageal segment and esophageal-stomach junction angle remain normal anatomical position and normal physiological sphincter, and the anti-reflux mechanism is not destroyed. Therefore, gastroesophageal reflux rarely occurs in this type, and about 1/3 of the large esophagus The side hole is prone to incarceration.

3. Hybrid split hole

The first two types coexist, the least common, the mixed type is often the gastroesophageal junction and the large curved side of the fundus is located on the sputum, the invasive part of the stomach is larger, up to 1/3 of the stomach or the entire stomach, or even part Omentum, colon, etc. are all inserted into the chest cavity, often with acute abdomen symptoms such as incarceration, strangulation and perforation.

Patients with this disease are often accompanied by different degrees of gastroesophageal reflux, plus local esophageal fistula after esophageal fistula squeezing, so reflux esophagitis and esophageal ulcer are common, recurrent inflammation and healing, can cause esophageal scar stenosis Sometimes inflammation spreads outside the esophageal wall, which can cause inflammation around the esophagus. The stomach that breaks into the chest can also cause local circulatory disturbances due to incarceration, torsion and squeezing, leading to gastric mucosal edema, congestion, infarction, erosion, Ulcers and bleeding.

The disease and reflux esophagitis are mutually causal and mutually promoting. In the middle and late reflux esophagitis, due to esophageal inflammation, erosion and ulceration, the esophagus is shortened, and the gastroesophageal junction is moved into the thoracic cavity. In the case of hiatal hernia, the Hiss angle formed by the esophagus and the stomach changes from an acute angle to an obtuse angle, and the relaxation of the ligament around the hiatus, together with the hiatal hernia itself, can relax the lower esophageal sphincter (LES), making anti-reflux Mechanism disruption, leading to the occurrence of reflux esophagitis.

Elderly esophageal hiatal hernia prevention

1. Three-level preventive measures for hiatal hernia

Primary prevention (cause prevention): The disease is frequent in the elderly, with the relaxation of the ligament around the esophagus, the widening of the esophageal hiatus and the increase of intra-abdominal pressure. Therefore, the prevention of the cause should focus on avoiding the factors of increased abdominal pressure, such as obese people should lose weight. Elderly chronic cough should be actively treated, habitual constipation in the elderly, should pay attention to diet adjustment, with medication, try to make bowel movements smooth; ascites active treatment; young people do not tighten the belt and so on.

Secondary prevention (early diagnosis and early treatment): The earlier the disease is discovered, the more effective the treatment is. There are mainly X-ray films, barium meal examination, convenient, high diagnosis rate, should be preferred, and those with predisposing factors should be checked early. Patients with obvious reflux symptoms should be treated with endoscopy, and early treatment after diagnosis, including measures to reduce abdominal pressure and treatment to reduce reflux (see gastroesophageal reflux disease treatment).

Tertiary prevention (diagnosis, treatment and rehabilitation): mainly for medical treatment, severe cases can be treated surgically.

2. Risk factors and interventions

(1) Habitual constipation, chronic cough, and obesity are the three major risk factors for this disease. They should be interfered early, including strengthening physical activity, increasing crude fiber in food, preventing influenza in winter and spring, and controlling chronic cough symptoms. Lose weight and so on.

(2) Severe chest and abdomen trauma surgery should try to ensure the normal position of the stomach and esophageal hiatus; in addition, suffering from esophagitis, esophageal ulcer should be treated early to prevent recurrence of esophageal scar contraction caused or aggravate the disease.

3. Community intervention

To strengthen the health and hygiene education for the elderly, the community should organize more elderly people to participate in appropriate physical exercise, and live healthy in cultural and sports activities; at the same time, guide the elderly to develop normal living habits, and pay attention to dietary regulation, through community health consultation, Elderly people with predisposing factors should be examined early, diagnosed early, and treated early.

Esophageal hiatal hernia complications in the elderly Complications, acute gastric dilatation, peptic ulcer, upper gastrointestinal bleeding

The most common cases are esophagitis, esophageal scar stenosis or supracondylar incarceration or strangulation, esophageal obstruction and acute gastric dilatation may occur, upper gastrointestinal bleeding is also more common, in addition, the disease can often be combined with digestive ulcer.

Esophageal hiatal hernia symptoms common symptoms esophageal reflux symptoms esophageal vagina foreign body sensation sinus esophageal ulcer coronary artery insufficiency dysphagia chronic cough nausea belching

In the hiatal hiatus, the sliding type hiatus is the most common. The sliding sputum makes the LES function incomplete, and the His angle becomes dull, which leads to the weakening of the anti-reflux effect of the gastric tube junction. Therefore, it is clinically the same as reflux esophagitis. Gastroesophageal reflux symptoms.

Symptom

(1) Burning sensation and acid reflux after sternum: the most common symptom, burning sensation from mild burning or fullness discomfort to more severe burning pain, mostly located behind the sternum (middle or lower 1/3), under the xiphoid Or two seasons of rib area, the pain can be released to the neck, back, upper chest, left shoulder and left arm, more than 0.5 ~ 1h after a full meal, like angina, with hernia or hiccups, supine, bent, cough or full meal After the increase in intra-abdominal pressure caused by forced air intake, it can be induced or aggravated; it can be relieved after standing position or vomiting, and it is relieved by 1 hour after the meal. Under normal circumstances, the small ones tend to have more pain, while the larger ones are more painful. Lighter, often accompanied by nausea, and sometimes more acidic stomach contents, called acid reflux.

(2) difficulty in swallowing or pain: accompanied by esophageal inflammation, erosion and ulceration, can be expressed as swallow pain, swallowing difficulties are more common in esophagitis with esophageal fistula, or with esophageal scar stenosis and huge esophageal fistula People who oppress the esophagus, when eating too cold, overheated or rough food, when the scar is narrow, the difficulty of swallowing is often persistent.

(3) cardiac symptoms: about 1/3 of patients may have precordial pain, paroxysmal arrhythmia, palpitations, chest tightness and tightness in the precordial area, sometimes difficult to identify with angina, myocardial infarction, esophageal hiatus Stimulation of the vagus nerve, reflexively causing coronary insufficiency, myocardial ischemic changes in the electrocardiogram, clinically similar to coronary heart disease, but the heart has no organic disease, called the esophageal-coronary syndrome, the same, this disease can induce and Aggravate angina.

(4) Other symptoms: those with esophagitis or esophageal ulcer may have a small amount of bleeding, fecal occult blood positive, may have iron deficiency anemia, the esophageal hiatus can be reflected in the esophageal hiatus to cause pharyngeal foreign body sensation, huge sputum oppression cardiopulmonary And the mediastinum produces symptoms such as palpitations, shortness of breath, cough, hair clips and shoulder pain.

2. Signs

There is usually no special finding when there is no complication, but the chest of the large esophageal hiatus can pull out the irregular drum sound zone and the voiced sound zone. When drinking water or being vibrated, the chest can smell and splash water.

Examination of esophageal hiatus hernia in the elderly

Blood routine is generally normal.

X-ray inspection

The diagnosis of esophageal hiatus hernia is the highest and most reliable. The injection of more air into the stomach, the lower head and the abdominal compression method can improve the diagnosis rate. Gastric mucosa is seen in the posterior part of the heart shadow or in the hernia sac. In the sliding type, the esophagogastric ring (stomach-esophageal junction) is an important indicator for diagnosing hiatal hernia. Huge or irreversible esophagus A hiatal hernia can be seen in the thoracic or chest radiograph. The gas-filled cyst can be seen in the left rear of the heart. When standing, the liquid level is still visible in the cystic cavity; if the cyst does not contain gas, it is left. The palpitations disappear or blur.

(1) X-ray signs of the diameter of the esophageal hiatus:

1 Upper esophagogastric ring (Sehatski ring): The esophagogastric ring is a symmetrical sinus of divergence in the wall of the sac, which is an important sign of the disease.

2 upper sac (ie chest stomach): sputum sac shadow on the left side of the sputum examination, the sac is divided into two parts by the esophageal ring, the upper part is the dilated esophagus-gastric area Stomach part.

3

4 Elevation and contraction of the lower esophageal sphincter (LES): When the esophageal hiatus is paralyzed, the LES moves up, possibly due to the action of gastric acid, causing the sacral contraction, and the LES becomes the upper end of the hernia sac.

(2) Indirect X-ray signs of hiatal hernia:

1 esophageal fissure widening (> 2cm);

2 sputum anti-inflow into the supraorbital sac (> 4cm wide);

3 esophageal stomach angle becomes dull;

A functional contraction ring appears on the upper part of the iliac crest.

Because the upper sac is not fixed, the negative test can not exclude the disease, such as clinical symptoms are suspicious, and the above indirect signs can be seen, it is appropriate to repeat the test multiple times, and take special inspection methods:

1 supine head low foot high, while increasing abdominal pressure;

2 prone position (left posterior oblique position), padding the upper abdomen, and continuously taking the expectorant under excessive stomach filling;

3 stomach full of back side standing bent.

2. Endoscopy

Esophagogastric electron endoscopy has diagnostic value for esophageal and gastroduodenal mucosa morphology and structure, and is useful for the diagnosis of esophageal hiatal hernia complications, but for the hiatus sac site, morphology and esophageal and gastric sac motility. Not as good as X-ray meal, the two methods complement each other, but endoscopy is still not a common method for diagnosing this disease.

Under the voyeur view: the sliding type of the sacral hole is seen on the dentate line (from the door opening > 3.0cm), the His angle disappears, and there is a certain distance from the esophageal sac, which has the performance of reflux esophagitis. I even saw a large curved side of the fundus and had submucosal hemorrhage.

Diagnosis and diagnosis of esophageal hiatal hernia in the elderly

Diagnostic criteria

In the clinical, we can see older people, body fat, and symptoms such as heartburn and nausea. We should be alert to this disease. We should further inquire about other factors that induce this disease, such as habitual constipation, chronic cough, often Doing flexion labor, history of surgery, history of lower chest and upper abdominal trauma, clinically, sliding hiatal hernia is the most common, often misdiagnosed as reflux esophagitis, both of which are more common, not just satisfied Diagnosis of fluid esophagitis causes missed esophageal hiatus hernia, dysphagia caused by paraesophageal fistula and mixed hemorrhoids is characterized by sudden onset, repeated episodes, and natural disappearance in a few hours or days, which is different from esophageal cancer; its main symptoms It is pain and bleeding caused by intrusion into the chest and obstruction caused by incarceration or difficulty in swallowing. The following imaging examinations can be used to confirm the diagnosis.

Differential diagnosis

The disease should be differentiated from angina pectoris, myocardial infarction, gastritis, peptic ulcer, upper gastrointestinal cancer, biliary tract disease, and gastrointestinal or throat neurosis. In patients with difficulty in swallowing, it should be differentiated from esophageal cancer, and esophagus. The difference in cancer is that the difficulty of swallowing in this disease occurs at the end of swallowing, not at the beginning; it is a long-term intermittent episode, rather than progressive deterioration; sometimes small mouth feeding is more likely to cause difficulty in swallowing than eating at a large mouth; Appears and lasts for a few minutes, hours or days, and can suddenly disappear or gradually ease.

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