Herniation

Question 1

Herniation?

Answer 1

• Abdominal organ moving out of a weakened area on the body wall or projection from one organ cavity to another.
• Part of an organ protrudes through a supporting or retaining structure (typically a muscle or fascia, as in the abdominal wall)

Question 2

Where does a herniation usually occur?

Answer 2

It usually occurs in the abdominal cavity

Question 3

What is the pathology of a herniation?

Answer 3

• Weakened retaining structure (eg. muscles)
• Increased intra-abdominal pressure (pressure within the abdominal cavity [such as in pregnant or obese patients] -> herniation)

Question 4

What can a weakened retaining structure be due to?

Answer 4

• Acquired (through an injury, surgery on the abdomen causing a weakened area at the incision point)
• aging (degenerative)
• congenital (born with a weakened wall)

Question 5

Hiatus?

Answer 5

” a gap in sequence, “ also where the esophagus goes through the diaphragm (the aperture/hole in the diaphragm for the esophagus)

Question 6

Hiatal hernia?

Answer 6

Part of the stomach moves up through the hiatus into the thoracic cavity d/t increased pressure in the abdominal cavity

Question 7

What are the causes of a hiatal hernia?

Answer 7

• Enlargement of the hiatus (variety of causes -> aging, injury, etc)
• Increase intra-abdominal pressure (such as with chronic constipation)

Question 8

What are the 2 types of hiatal hernias?

Answer 8

1. Sliding or Axial Hernia

2. Paraesophageal, Non-axial or “rolling” hiatal hernia

Question 9

Out of the 2 hernias, which one is more common?

Answer 9

Sliding or axial hernia (accounts for 95% of hiatal hernias)

Question 10

Gastroesophageal junction (GEJ)?

Answer 10

Where the esophagus and the upper portion of the stomach join

Question 11

Sliding or axial hernia?

Answer 11

The GEJ and part of the stomach “slide” up into the thoracic cavity through the hiatus. [Results in a bell-like protrusion]

Question 12

Manifestations of sliding/axial hernia

Answer 12

• 50% are asymptomatic (no treatment)
• chest pain
• gastric reflux
• heart burn

Question 13

pH of hydrochloric acid?

Answer 13

~2 pH

Question 14

Why does gastric reflux occur in an axial/sliding hernia?

Answer 14

The hiatus squeezes on the stomach and the cardiac sphincter cannot stay closed due to increased pressure so the contents move up into the esophagus causing gastric reflux

Question 15

When will gastric reflux not be as bad?

Answer 15

When the stomach is empty because there will bee no stomach contents to be pushed up into the esophagus (symptoms worsen after a meal)

Question 16

Paraesophageal, non-axial or “rolling” hiatal hernia?

Answer 16

In this type of hernia, the gastroesophageal junction (GEJ) stays below the diaphragm. A non-upper part of the stomach enters the thoracic cavity (the fundus)

Question 17

Manifestations of Non-axial hernia?

Answer 17

Chest pain, dyspnea, and fullness

Question 18

Why does reflux not occur in non-axial hernia?

Answer 18

No reflex occurs because the hiatus is not squeezing on the upper part of the stomach causing contents to be projects into the esophagus.

Question 19

Why does dyspnea occur in a non-axial hernia?

Answer 19

Depending on the extent of the protrusion, the herniated fundus can take up space in the thoracic cavity that may impede left lung expansion causing difficulty breathing

Question 20

Why does fullness occur in a non-axial hernia?

Answer 20

The herniated portion of the stomach forms a “mini stomach” that will get full very easily. This activates stretch receptors in the brain resulting in the patient having a false sense of being full.

Question 21

Diagnostics for hiatal hernia

Answer 21

Scopes, barium swallow

Question 22

Treatment of hiatal hernias?

Answer 22

• least invasive first -> lifestyle modifications (modify diet, avoid foods that increase the secretion of acid, smaller frequent meals, do not bend down abruptly, sleep with HOB elevated, etc)
• Drugs for symptoms such as gastric reflux, heartburn etc. No drug can fix the herniation: antacids, proton-pump inhibitors, H2 receptor antagonists
• Surgery if discomfort is severe and function of the heart and lungs is impacted. [Fundoplication]

Question 23

Proton-pump inhibitors?

Answer 23

Inhibit the pumping of H+ ions, resulting in decrease secretion of HCl

Question 24

H2 Receptor Antagonists?

Answer 24

Block the H2 receptor and block the synthesis of HCl

Question 25

Who does inguinal hernia occur in more?

Answer 25

Men

Question 26

What is the function of inguinal hernia in men & women?

Answer 26

Men: Allows structures of spermatic cord to pass to and from the testis to the abdomen
Women: Allows round ligament of the uterus to pass from the uterus to the labium majus

Question 27

Indirect inguinal hernia?

Answer 27

the intestines enter the inguinal canal

Question 28

Direct inguinal hernia?

Answer 28

the intestines exit through the body wall

Question 29

What does the inguinal hernia require?

Answer 29

• weakened aperture (opening) of inguinal canal

- increased intra-abdominal pressure

Question 30

Treatment for inguinal hernia?

Answer 30

Must be repaired with surgery d/t extensive amount of pain