Hernias of the esophagus

Hernias of the esophageal aperture of the diaphragm can be congenital or acquired, and also distinguish sliding and paraseophageal hernias. With a sliding hernia, the cardiac compartment of the stomach moves freely into the posterior mediastinum through the enlarged esophageal opening of the diaphragm. Such a hernia does not give an infringement. With paraezofageal hernias, which are much less common, the cardiac area of ​​the stomach is fixed, and its vault or antrum, and sometimes other abdominal organs (small, large intestine, omentum) are displaced into the posterior mediastinum. In this case, there may be an infringement of the displaced organ, which is manifested by sharp pain behind the sternum, resembling angina, suddenly a dysphagia or vomiting with an admixture of blood, symptoms of intestinal obstruction. Radiologic examination reveals a gas bubble of the stomach in the posterior mediastinum, contrast research examines the displacement of the lower third of the esophagus, the absence of contrast material entering the stomach or evacuation from it. With late diagnosis, necrosis of an injured organ occurs with the development of mediastinitis, empyema of the pleura, peritonitis.

Slipping hernia of the esophageal opening of the diaphragm is clinically manifested by reflux esophagitis, as well as the lack of cardiac pulp. There is practically no fundamental difference between these diseases, both clinically and from a medical point of view. Lack of cardia with reflux of gastric contents into the esophagus is more often secondary and can be caused by scleroderma, neurological diseases (pseudobulbar paralysis, diabetic neuropathy), chronic alcoholism, obesity, ascites, constipation, prolonged bed rest, stress. A number of medicines contribute to the development of reflux disease of the esophagus: anticholinergic drugs, beta-adrenergics, glucagon, antispasmodics and coronarolytics, nicotine.

Symptoms, course. Burning and dull pain behind the sternum, the xiphoid process and in the epigastrium. Often the patient is diagnosed with angina for a long time and treated with coronarolytics. The pain increases in the horizontal position of the patient, with the body tilting ("the symptom of shoe lacing"). The pain is accompanied by a belching, heartburn. With the progression of the disease, the pain becomes almost constant, it is not withdrawn by drugs. Reflux esophagitis may result in the development of an ulcer followed by scarring, leading to stenosis of the esophagus and the appearance of dysphagia.

The diagnosis is made on the basis of the clinical picture of the disease, the X-ray study in the Trendelenburg position (horizontal position with the raised end of the X-ray table), at which flow of contrast material from the stomach into the esophagus is noted. Clarification of the diagnosis is possible with the use of manometry, pH-metry, esophagoscopy.

Despite the expressed clinical manifestations of reflux, sometimes in endoscopic examination of pathology it is not possible to identify. In this case, the clinical picture is due to spasm of the esophagus when the contents of the stomach are thrown into the esophagus. According to the endoscopic picture, the following stages of esophagitis are distinguished: I - single erosions against the background of infiltration of the mucous membrane; II-appearing erosions in the lower third of the esophagus; III - circular superficial ulceration; IV - deep ulcers or peptic stenosis of the esophagus.

Complications of reflux disease of the esophagus. Prolonged casting of gastric contents leads to gastric transformation of the mucosa of the esophagus, the emergence of Barrett ulcers on the background of the ectopic mucus membrane, which have a very high tendency to malignancy. Barrett's ulcer is usually accompanied by a shortening of the esophagus. Other complications include perforations, bleeding, scar stricture.

Treatment in the vast majority of cases is conservative. Frequent fractional meals; Do not lie down after eating for 3-4 hours (the last meal should be 3-4 hours before bedtime), sleep with the raised head end of the bed. Before eating, prescribe vegetable oil - 1 teaspoon before meals, Almagel. It is necessary to exclude smoking and the use of alcohol, to monitor the regular emptying of the intestine.

With ineffectiveness of conservative treatment, repeated bleeding, stenosis of the esophagus, surgical treatment is indicated. Often used esophagofunduplication according to Nissen. With cicatricial esophageal stenosis, it may be necessary to resect it.

The outlook is usually favorable.