内镜食管裂孔疝

Endoscopy of Hiatal Hernia

发布时间：2013-04-12

The endoscopic diagnosis of hiatal hernia (sliding type) relies on direct and indirect criteria during the esophagoscopic or gastroscopic approach. A wide separation between the anatomic and mucosal oesophago-gastric junction, the presence of a so-called Schatzki-ring, a wandering junction with sliding gastric mucosal folds during inspiration and two ring-like structures are important. Whereas radiology seems to be superior to endoscopy in the diagnosis of asymptomatic hiatus hernia, esophagoscopy may reveal sequelae of reflux like esophagitis, erosions, ulcers and strictures. Peptic esophagitis is found in about 10% to cause upper gastrointestinal haemorrhage.

A hiatal hernia is an anatomical abnormality in which part of the stomach protrudes through the diaphragm and up into the chest. Although hiatal hernias are present in approximately 15% of the population, they are associated with symptoms in only a minority of those afflicted.
Normally, the esophagus (or food tube) passes down through the chest, crosses the diaphragm, and enters the abdomen through a hole in the diaphragm called the esophageal hiatus. Just below the diaphragm, the esophagus joins the stomach.
In individuals with hiatal hernias, the opening of the esophageal hiatus (hiatal opening) is larger than normal, and a portion of the upper stomach slips up or passes (herniates) through the hiatus and into the chest. Although hiatal hernias are occasionally seen in infants, where they probably have been present from birth, most hiatal hernias in adults are believed to have developed over many years.
Other potentially contributing factors include: 1) a permanent shortening of the esophagus (perhaps caused by inflammation and scarring from the reflux or regurgitation of stomach acid) which pulls the stomach up; and 2) an abnormally loose attachment of the esophagus to the diaphragm which allows the esophagus and stomach to slip upwards.

Symptoms

The vast majority of hiatal hernias are of the sliding type, and most of them are not associated with symptoms. The larger the hernia, the more likely it is to cause symptoms. When hiatal hernias produce symptoms, they almost always are those of gastroesophageal reflux disease (GERD) or its complications. This occurs because the formation of the hernia often interferes with the barrier (lower esophageal sphincter) that prevents acid from refluxing from the stomach into the esophagus. Additionally, it is known that patients with GERD are much more likely to have a hiatal hernia than individuals not afflicted by GERD. Thus, it is clear that hiatal hernias contribute to GERD. However, it is not clear if hiatal hernias alone can result in GERD. Since GERD occurs in the absence of a hiatal hernia, factors other than the presence of a hernia can cause GERD.

Normally, there are several mechanisms to prevent acid from flowing backwards (refluxing) up into the esophagus. One mechanism involves a band of esophageal muscle where the esophagus joins the stomach called the lower esophageal sphincter that remains contracted most of the time to prevent acid from refluxing or regurgitating. The sphincter only relaxes when food is swallowed, so the food can pass from the esophagus and into the stomach. The sphincter normally is attached firmly to the diaphragm in the hiatus, and the muscle of the diaphragm wraps around the sphincter. The muscle that wraps around the diaphragm augments the pressure of the contracted sphincter to further prevent reflux of acid.

Another mechanism that prevents reflux is the valve-like tissue at the junction of the esophagus and stomach just below the sphincter. The esophagus normally enters the stomach tangentially so that there is a sharp angle between the esophagus and stomach. The thin piece of tissue in this angle, composed of esophageal and stomach wall, forms a valve that can close off the opening to the esophagus when pressure increases in the stomach, for example, during a belch.

When a hiatal hernia is present, two changes occur. First, the sphincter slides up into the chest while the diaphragm remains stationery. As a result, the pressure normally generated by the diaphragm overlying the sphincter and the pressure generated by the sphincter no longer overlap, and as a result, the total pressure at the gastro-esophageal junction decreases. Second, when the gastro- esophageal junction and stomach are pulled up into the chest with each swallow, the sharp angle where the esophagus joins the stomach becomes less sharp and the valve-like effect is lost. Both changes promote reflux of acid.

Diagnosis

Hiatal hernias are diagnosed incidentally when an upper gastrointestinal endoscopy is done during testing to determine the cause of upper gastrointestinal symptoms such as upper abdominal pain.

内镜诊断食管裂孔疝（滑动型）在食道镜或胃镜的方法依赖于直接和间接的标准。广泛分离之间的解剖和粘膜oesophago的胃交界，存在所谓的Schatzki环，一个流浪交界滑动胃粘膜皱襞在灵感和两个环状结构是很重要的。而放射似乎要优于内镜诊断无症状裂孔疝，食管镜检查可以揭示回流后遗症，如食管炎，糜烂，溃疡和狭窄。消化性溃疡食管炎被发现在10％左右，造成上消化道出血，食管裂孔疝是通过隔膜进入胸腔的胃凸出部分的解剖异常。裂孔疝疝气虽然目前约15％的人口，他们都与只有少数那些患有症状。通常情况下，食管（或食品管）向下传递通过胸部，穿过膈肌，进入腹部通过膈肌食管裂孔称为一个洞。正下方的膜片，食道和胃连接个人裂隙疝气，食管裂孔（裂孔疝开口）的开口大于正常，和胃上部的一部分的滑倒，或通过（疝）通过间断进入胸腔。裂孔疝疝气虽然偶尔可见的婴幼儿，他们可能已经从出生，最裂孔疝疝气成人认为已经发展了多年。其他潜在因素包括：1）一个永久性的食管缩短（可能造成的从回流或胃酸返流的炎症和疤痕）拉胃涨; 2）异常松散附着在食道的隔膜让食道和胃向上滑。症状绝大多数裂孔疝疝气滑动型，其中大部分是不相关的症状。疝越大，越有可能是引起的症状。裂孔疝疝气症状产生时，他们几乎总是那些胃食管反流病（GERD）或其并发症。这是因为形成的疝往往干扰从胃到食道回流，防止酸与所述势垒（下食管括约肌）。此外，它是已知，GERD患者更可能有食管裂孔疝由胃食管反流病折磨的不是个人。因此，很显然，裂孔疝疝气有助于GERD。然而，目前尚不清楚如果单靠裂孔疝疝气可能导致胃食管反流。由于GERD发生在没有裂孔疝，疝气的存在下以外的因素可以引起胃食管反流病，通常情况下，有几种机制，以防止倒流到食道（回流）的酸。涉及到一个机制带食管肌层，食管和胃连接，称为食管下括约肌，签约的大部分时间，防止胃酸回流或反刍。括约肌放松，当食物被吞下，所以可以通过食物从食道进入胃。括约肌通常被牢固地连接在隔膜上的间断，肌肉的隔膜环绕括约肌。肌肉环绕隔膜增强承包括约肌的压力，以进一步防止回流酸，另一种机制，防止回流阀样组织交界处的食道和胃，略低于括约肌。正常食管进入胃，食道和胃之间，有一个尖尖角切线。薄薄的一片组织在这个角度看，食管和胃的壁组成，形成阀门可以关闭开放的食管在胃中压力增加时，例如，在一个嗝。当裂孔疝存在，两个发生变化。首先，括约肌向上滑动进入胸腔而膜片仍然文具。其结果是，通常覆盖括约肌的括约肌不再重叠所产生的压力由膜片产生的压力，其结果是，上面的胃食管结合部减小的总压力。其次，当拉升的胃食管交界处和胃进入胸腔每次吞服，尖尖角，食道和胃连接变得越来越尖锐，丢失阀般的效果。这两个变化推动回流酸。诊断食道裂孔疝疝气时偶然诊断上消化道内镜检查是在做测试，以确定上消化道症状，如上腹疼痛的原因。

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