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Toronto Notes 2019 Thoracic Surgery
Treatment
• drainplacementbyinterventionalradiology(preferred),laparoscopy,andopendrainage
• subsequentantibioticcoverage;ceftriaxone+metronidazoleorpiperacilin-tazobactam(Pip-Tazo)
General Surgery and Thoracic Surgery GS13
Paralytic Ileus
• seeBowelObstruction,GS21 Delirium
• seePsychiatry,PS19andNeurology,N20 Thoracic Surgery
Hiatus Hernia
Esophagus Diaphragm
Stomach GE junction
Esophagus Stomach
Diaphragm
GE junction
Esophagus GE junction
Stomach Diaphragm
Esophagus Stomach GE junction
Diaphragm
Differential Diagnosis of Hiatus Hernia
GI Causes
Cholelithiasis Diverticulitis Peptic ulcer Achalasia Pancreatitis GERD Gastritis
Non-GI Causes
MI
Angina Pericarditis
Normal Anatomy
Sliding Hiatus Hernia
Mixed Hiatus Hernia
Paraesophageal Hiatus Hernia Figure 6. Types of hiatus hernia
SLIDING HIATUS HERNIA (TYPE I)
• seeFigure6
• herniationofboththestomachandthegastroesophageal(GE)junctionintothorax • 90%ofesophagealhernias
Risk Factors
• age
• increasedintra-abdominalpressure(e.g.obesity,pregnancy,coughing,andheavylifting) • smoking
Clinical Features
• majorityareasymptomatic
• herniasfrequentlyassociatedwithGERDduetodecreasedcompetenceofLES
Complications
• mostcommoncomplicationisGERD
• othercomplicationsarerareandarerelatedtoreflux
• esophagitis(dysphagia,andheartburn)
• consequencesofesophagitis(pepticstricture,Barrett’sesophagus,andesophagealcarcinoma)
• extra-esophagealcomplications(aspirationpneumonitis/pneumonia,asthmatypebronchospasm,
cough, and laryngitis)
Investigations
• bariumswallow,endoscopy(esophago-gastroscopy),oresophagealmanometry(techniquefor measuring LES pressure)
• 24hesophagealpHmonitoringtoquantifyreflux
• endoscopywithbiopsytodocumenttypeandextentoftissuedamageandruleoutesophagitis,Barrett’s
esophagus, and cancer
© Jerusha Ellis 2012