Symptom >> Surgical >> General Surgery

Gastric incarceration

Introduction
Cause
Examine
Diagnosis

Introduction

Introduction Gastric incarceration is a clinical manifestation of paraesophageal fistula. The normal esophageal hiatus is divided into left and right wings by the left and right lumbar vertebrae 1st to 4th lumbar vertebrae. It can also be formed from the left ankle (1st to 3rd lumbar vertebrae). It is formed like a neck. The longitudinal diameter of the hole is 3~5cm and the transverse diameter is 2cm. . There are several layers of tissue at the esophageal hiatus, such as the pleura, mediastinal fat, intrathoracic fascia, and intra-abdominal fascia, which separate the chest from the abdominal cavity. The esophageal hiatus plays an important role in reflux. The muscles of the esophageal hiatus around the gastroesophageal junction are like spring clips, which rhythmically contract and synchronize with the inspiratory movement.

Cause

Cause

Cause: The cause of esophageal hiatus hernia: normal esophageal hiatus is divided into left and right wings by the left iliac muscle 1st to 4th lumbar vertebrae, and can also be caused by left ankle (1st to 3rd lumbar vertebrae), as if formed around the neck, the hole The longitudinal diameter is 3 to 5 cm and the transverse diameter is 2 cm (Fig. 1). There are several layers of tissue at the esophageal hiatus, such as the pleura, mediastinal fat, intrathoracic fascia, and intra-abdominal fascia, which separate the chest from the abdominal cavity. The esophageal hiatus plays an important role in reflux. The muscles of the esophageal hiatus around the gastroesophageal junction are like spring clips, which rhythmically contract and synchronize with the inspiratory movement. When the muscles around the esophageal hiatus contract, the esophagus is pulled down and the bending angle is increased, which helps the lower esophagus to close, thereby preventing gastroesophageal reflux.

Examine

an examination

Related inspection

Fiber endoscopy

Diagnosis: Clinical features of paraesophageal fistula: The clinical manifestations of esophageal paralysis are mainly due to mechanical effects. The patient can tolerate for many years, but the invaded stomach can be compressed after the mediastinum, esophagus, and lungs, and the whole stomach can be turned over. Intrusion into the chest leads to gastric torsion and obstruction, and it is prone to gastric incarceration, blood flow disorder, and even necrosis and perforation. Unlike the esophageal hiatus sliding sputum, this disease is less likely to have gastroesophageal reflux.

(1) Pain: The muscle fibers of the diaphragmatic muscles may be pulled by the stomach through the holes, or the stomach is twisted or twisted by the large esophageal sputum or the whole stomach. The pain caused by the muscles of the abdomen muscles is mostly located in the xiphoid process and radiates to the back or ribs in the same plane, sometimes spreading to the neck, jaw, upper chest, left shoulder and left arm, and more Occurs after a full meal. Small sacs tend to be more painful, while those with larger sacs are less likely to have severe pain. Severe cramps can occur when the stomach is twisted and twisted.

(2) difficulty in swallowing, dysphagia: more due to large esophageal fistula compression of the esophagus, infiltration of the stomach into the sputum delay or the end of the esophagus kinks. When the esophageal fistula is difficult to swallow, the mechanical obstruction of food through the esophageal hiatus is very slow. Patients often have discomfort and nausea in the posterior sternal, but there are few esophagitis.

(3) upper gastrointestinal bleeding: the stomach into the chest cavity due to poor emptying and gastritis, ulcers can occur in upper gastrointestinal bleeding, vomiting brown bloody substances, 20% to 30% of cases of esophageal fistula can occur severe hematemesis . Upper gastrointestinal bleeding can also occur when intubation occurs in the whole stomach.

(4) huge esophageal paralysis: 1 reflux symptoms: patients with giant hiatal hernia may have post-sternal burning pain and reflux symptoms, a small number of esophagitis. Some scholars have reported that a group of patients with large hiatal hernias have 40% of those with nausea and nocturnal aspiration, 86% of post-sternal burning pain and reflux, and 20% of endoscopy patients have esophagitis. 2 heart, lung and mediastinal compression symptoms: huge esophageal fistula compression of the heart, lungs and mediastinum can produce palpitations, chest tightness, paroxysmal arrhythmia, anterior pegment, shortness of breath, cough, cyanosis, difficulty breathing, shoulder and neck Pain and many other symptoms.

3 signs: huge esophageal hiatus hernia can be diagnosed in the chest of the drumy sound zone and voiced area. After drinking or being vibrated, the chest can hear bowel sounds and splashing water.

Diagnosis

Differential diagnosis

Differential diagnosis: patients with esophageal hiatal hernia due to unclear diagnosis, repeated pain, poor efficacy and a variety of other symptoms make patients with anxiety, nervous mood and multiple consultations. Due to the variety and variety of symptoms, there are reports of more than 30 kinds of diseases that have been diagnosed.

1. Chronic bronchitis, pulmonary infection, partial esophageal hiatus hernia, especially in neonates or infants, due to the transgastric reflux to the pharyngeal stomach contents can be accidentally inhaled into the trachea, causing long-term chronic cough, cough, Even bronchial asthma attacks are often diagnosed in internal medicine with repeated respiratory infections and are misdiagnosed as chronic bronchitis and pneumonia. Symptoms, signs, and X-ray abnormalities of chronic bronchitis or pulmonary infection are limited to the lungs, but this disease has symptoms other than respiratory symptoms, such as postprandial pain, post-sternal pain, acid reflux, and sternal burning. X-ray fluoroscopy and plain film examination can also be changed in addition to the lungs. Upper gastrointestinal X-ray examination, gastroscopy and CT examination are helpful for diagnosis and differential diagnosis.

2. Coronary heart disease in adults with esophageal hiatal hernia is similar to the onset age of coronary heart disease. The clinical symptoms of some patients are similar to the manifestations of angina pectoris, so it is often misdiagnosed, or the disease is often missed when coexisting with coronary heart disease. According to He Qiuyu et al, 75 cases of esophageal hiatal hernia were reported, including 46 cases (61.3%) with pain in the lower part of the sternum and 29 cases (38.7%) with pain in the precordial area. The duration of chest pain lasted for several minutes to more than 1 hour, mostly from 20 to 30 minutes. Chest pain was radiated to the upper chest, back, neck, left shoulder and left arm in 32 cases (42.7%); routine electrocardiogram and 24h dynamic electrocardiogram in intermittent chest pain were ST-segment depression, T-wave low-level inversion or arrhythmia, confirmed by further examination There were 9 cases of esophageal hiatal hernia with coronary heart disease; the normal electrocardiogram was normal during the intermittent period of chest pain, and the myocardial ischemic change was observed in the 24h dynamic electrocardiogram when the chest pain occurred, and there was radiation pain in the neck, left shoulder and left arm, but the secondary extreme activity plate Six patients were negative in the test; only 17 cases (22.7%) were diagnosed as hiatal hernia and X-ray or gastroscopy, and the remaining 58 cases were diagnosed and/or misdiagnosed as 52 cases of coronary heart disease ( 69.3%). Comprehensive literature, the reasons for misdiagnosis include: 1 The clinical manifestations of the two are similar. Esophagitis and esophageal ulcers in esophageal hiatus can induce esophageal spasm and post-sternal pain; sacs move, twist or larger esophageal fistula, vagus nerves around the sac or around the sac are stimulated, causing coronary reflex Insufficient arterial blood supply, electrocardiogram and 24h dynamic electrocardiogram showed myocardial ischemia-like changes; about 1/3 of patients with esophageal hiatal hernia showed precordial pain, paroxysmal arrhythmia, chest tightness and tightness in the precordial area, and pain can be radiated To the back, neck, ear, left shoulder and left arm; its pathogenesis, pain, chest pain, chest pain duration and nitroglycerin or isosorbide dinitrate (relieving heart pain) are similar to coronary heart disease and angina Sometimes difficult to identify; 2 the age of onset is similar. Some scholars have reported that the incidence of this disease is less than 40% under 40 years old, 38% over 50 years old, and 69% over 70 years old. This age is also a good age for coronary heart disease, and the incidence of coronary heart disease is much higher than that of esophageal hiatus. It is one of the most common diseases leading to rapid death in the elderly, and clinicians attach great importance to it. Therefore, in patients with middle-aged and elderly patients with hiatal hernia, if there is chest pain, even if there are obvious upper gastrointestinal symptoms, it is often considered as cardiogenic chest pain, especially in patients with diabetes, hypertension and hyperlipidemia; Coexist, ignoring the existence of hiatal hernia. As mentioned above, the age of both of them is the same, so the coexistence of the two is also very common. Because the symptoms of the two are similar, coronary heart disease is extremely common. Therefore, when the above two diseases coexist in the same patient, the diagnosis of coronary heart disease is often considered and satisfied, leading to missed diagnosis of hiatal hernia. 4 The coronary artery dilatation drug is ignored. The relief of non-cardiac chest pain. Coronary artery dilatation drugs such as nitroglycerin, isosorbide dinitrate (discardiamine), calcium antagonist, and nifedipine (xintongding) can also alleviate or relieve the spasm of the esophageal smooth muscle and diaphragm, and reduce the pain of the posterior sternum. Or relieve, which is conducive to the reduction and relief of the vagus nerve, thus blocking the reflex sputum of the coronary artery, plus the direct expansion of the coronary artery, in the case of chest pain in patients with esophageal hiatal hernia, after taking the above drugs, Some patients have post-sternal pain or pain in the precordial area. Due to the lack of understanding of the anatomy and pathophysiological characteristics of esophageal hiatus hernia, the mitigating effect of coronary dilatation drugs on non-cardiac chest pain is neglected. It is satisfied that the diagnosis and "effectiveness" of coronary heart disease are misdiagnosed. One of the reasons for being missed for coronary heart disease or coexistence with coronary heart disease.

In summary, the chest pain of hiatal hernia is easily misdiagnosed as a coronary heart attack. However, as long as the anatomy, pathology, pathophysiology and clinical features are mastered, the following points can be used for identification: 1 Although the conventional electrocardiogram and 24h dynamic electrocardiogram of the disease are ST-segment depression, T-wave low-level inversion or arrhythmia, but chest pain interval The normal electrocardiogram was normal, and the submaximal activity plate test was negative. In patients with coronary heart disease, the conventional electrocardiogram was abnormally changed during the intermittent period of chest pain, and the submaximal activity plate test was positive. 2 There was no significant relationship between chest pain and fatigue in patients with esophageal hiatal hernia, but it was closely related to diet. Chest pain often occurs after 0.5 to 1.0 hours after a full meal. Factors such as supine, bending, coughing, exerting force or exerting defecation may induce or aggravate chest pain, while semi-recumbent, standing, walking, vomiting sour water or Chest pain is relieved or relieved after gastric contents. Chest pain in sleep, gradually relieved after sitting up. Coronary heart disease angina has no such characteristics; 3X-ray examination may have sacral sacral sac, sputum on the gastric mucosa, lower esophageal sphincter rise and contraction, gastroesophageal reflux, etc.; 4 endoscopy can be seen: dentate line shift >2cm, the lumen of the end of the esophagus is widened and straightened, the lower esophagus, the cardia, the gastric cavity is on the same longitudinal axis, the gastric juice flows back into the esophagus, and the gastric mucosal folds are turned into the thoracic cavity through the hiatus of the esophagus to induce gastric mucosa in patients with nausea. Such as walnut-like sputum into the esophagus, the esophageal sputum can be seen in the gastric mucosa sac cavity with inhalation, exhalation and bulging and shrinking, endoscopic performance of reflux esophagitis; 5 pairs of patients without coronary heart disease take nitroglycerin, Coronary artery dilatation drugs such as isosorbide dinitrate (disgusting heart) or nifedipine (heart pain) are relieved in some patients, but the onset of action is slow or the effect is not certain. The application of cimetidine (cimetidine), ranitidine, famotidine and gastric motility drugs (domiperone, cisapride, etc.) can significantly relieve the symptoms of chest pain and prolonged seizure interval.

3. Cholecystitis, cholelithiasis, esophageal hiatus hernia can be caused by xiphoid pain, hernia sac and sputum contents sliding up and down the esophageal hiatus to stimulate the vagus nerve reflex caused by right upper quadrant pain, nausea and vomiting, easy to misdiagnose cholecystitis, cholelithiasis. Or both of them coexist when they are only satisfied with the diagnosis of cholecystitis and cholelithiasis and missed diagnosis. However, cholecystitis and cholelithiasis often have fever, jaundice, elevated blood levels, abnormal liver function, and B-ultrasound and CT examinations can show biliary system inflammation and stone imaging. In patients with simple esophageal hiatal hernia, there were no changes in jaundice and abnormal liver function. B-ultrasound and CT examinations did not have hepatobiliary inflammation or stone imaging.

When patients with symptoms such as xiphoid pain, right upper quadrant pain, nausea and vomiting can not only think of hepatobiliary diseases, but also consider the possibility of esophageal hiatus hernia. As long as the disease is thought, X-ray angiography should be performed on the digestive tract. If you can see the sacral sac, the gastric mucosa, the lower esophageal sphincter rise and contraction, gastroesophageal reflux and other signs, you can confirm the diagnosis.

4. Gastrointestinal hemorrhage, anemia due to esophageal mucosal erosion ulcer or repeated intrusion caused by mucosal tearing of the cardia, invasion of gastric ulcer, esophageal hiatus hernia may have gastrointestinal bleeding, the incidence rate of 2.5% to 20.7%. It is often characterized by a small amount of black stool or a small amount of fresh blood. In severe cases, a large amount of hematemesis and melena can be caused. Severe anemia can also be the first symptom. Frequently diagnosed as clinically more common blood diseases, gastrointestinal inflammation or ulcers, bleeding caused by digestive tract tumors, neglecting the possibility of esophageal hiatus hernia. However, as long as patients with gastrointestinal bleeding and anemia think of this disease, timely gastroscopy and digestive tract X-ray angiography can be diagnosed.

5. Digestive tract diseases Patients with esophageal hiatal hernia are more likely to have symptoms such as esophagitis, gastritis, ulcer disease, esophageal cancer, etc. due to lower pain in the xiphoid process, acid reflux, burning of the upper abdomen, and poor swallowing. However, the acid reflux and sternal burning pain caused by hiatal hernia can be aggravated by supine and increased abdominal pressure (bending, lifting weights, forced bowel movements, etc.), simple esophagitis, gastritis, ulcer disease, acid reflux, sternal burning This kind of pain does not have this feature. Due to esophageal mucosal edema, erosion, ulceration or motor dysfunction, the swallowing caused by esophageal hiatus hernia is mostly intermittent, recurrent or lasting for several hours, often relieved after a few days; and esophageal cancer and cardia cancer are difficult to swallow. Sexual aggravation, accompanied by history of weight loss. Chronic esophagitis, ulcers, tumor infiltration, etc. can cause esophageal contracture, long-term upward traction of the esophagus in the thoracic cavity, the lower esophagus and the cardia gradually enter the sputum and cause esophageal hiatal hernia; this situation must be carefully asked about the history and physical examination, and Identification was performed by X-ray examination, endoscopy and pathological examination.

6. Pneumothorax, empyema, esophageal hiatus, perforated gastric ulcer perforated, the gastric gas leaks into the thoracic cavity to compress the lung tissue, the patient has chest pain and difficulty breathing. Due to the negative pressure in the thoracic cavity, the gas in the stomach can continuously enter the pleural cavity, and the above symptoms are progressively aggravated. The flank space of the affected side was widened, the percussion was a drum sound, and the auscultation of the lungs was weakened or disappeared. X-ray fluoroscopy has no free gas under the armpit, gas in the thoracic cavity, lung tissue compression collapse, mediastinal shift. Symptoms, signs and auxiliary examinations are similar to pneumothorax, which is very easy to misdiagnose. However, patients with perforated gastric ulcer in the esophageal hiatus hernia often have kyphosis pain, post-sternal burning pain, acid reflux, burning of the upper abdomen, poor swallowing, etc., and the above symptoms are often due to supine and Increase abdominal pressure and increase; insert X-ray fluoroscopy into the stomach tube, visible stomach tube shadow in the chest cavity, injected into the chest cavity of water-soluble contrast agent can be developed.

After incarceration of the gastric perforation, the digestive juice in the stomach leaks into the chest cavity and stimulates the pleura, which is characterized by severe chest pain and difficulty in breathing due to compression of the lung tissue. X-ray examination showed a dense shadow in the chest cavity, with a liquid level, which was misdiagnosed as empyema. The difference between the disease and empyema is the nature of the thoracic drainage fluid and the amount of drainage. Because the retention fluid and secretion in the stomach can continue to enter the pleural cavity, the drainage volume after intubation of the gastric perforation is more, the liquid drawn out is dark brown, the food residue is visible in the non-fasting perforation, and the chest pain and dyspnea, the lung breath sound of the affected side Low is not relieved by drainage, X-ray examination of lung collapse still exists. The condition is more critical than the general empyema. If the treatment is improper or not timely, septic shock can quickly occur and die.

7. Congenital pulmonary cysts Congenital pulmonary cysts are caused by abnormal lung development in the embryo, with single and multiple, closed cysts and open cysts. Those who do not communicate with the bronchus are closed cysts, and those that communicate with the bronchus are open cysts. The open cyst mucus is discharged into the bronchus through a small passage. Sometimes a one-way "live flap" is formed between the bronchus and the cyst cavity. When inhaling, the air is more likely to enter the capsule cavity and expand, and the gas in the capsule cannot be discharged when exhaled. Sexual cysts compress the normal lung tissue of the affected side and displace the mediastinum and heart. The contralateral lung can also be compressed and have symptoms such as difficulty breathing. After perforating the gastric ulcer embedded in the hernia sac, the gastric air leaked into the chest to compress the lung tissue, and the symptoms and signs of dyspnea were similar. However, congenital pulmonary cysts have no gastrointestinal image in the thoracic cavity, and patients with esophageal hiatal hernia often have a history of xiphoid pain, upper abdomen burning, post-sternal burning pain, acid reflux, poor swallowing, etc., and X The sacral sac shadow can be seen on the left side of the line. When the barium meal is examined, a large gastric mucosa shadow can appear on the sputum, and the widened esophageal hiatus continues to the bottom of the infraorbital stomach.

8. Pregnancy reaction The esophageal hiatal hernia should be differentiated from the pregnancy reaction. The symptoms of pregnancy reaction occur in the first 3 months of pregnancy, and the symptoms gradually improve or disappear with the increase of pregnancy. The esophageal hiatal hernia is related to the increase of abdominal pressure. More often after the fifth month of pregnancy, the closer to the third trimester of pregnancy, the more severe the symptoms.

(4) huge esophageal paralysis:

1 reflux symptoms: patients with giant hiatal hernia may have post-sternal burning pain and reflux symptoms, a small number of esophagitis. Some scholars have reported that a group of patients with large hiatal hernias have 40% of those with nausea and nocturnal aspiration, 86% of post-sternal burning pain and reflux, and 20% of endoscopy patients have esophagitis.

2 heart, lung and mediastinal compression symptoms: huge esophageal fistula compression of the heart, lungs and mediastinum can produce palpitations, chest tightness, paroxysmal arrhythmia, anterior pegment, shortness of breath, cough, cyanosis, difficulty breathing, shoulder and neck Pain and many other symptoms.