Let us now move on to
Diverticulae and Hernia.
We’ll first begin with diverticulum.
So what does a diverticulum
mean in general?
It means an outpouching.
There’s a weakening of that particular structure in
which there is an outpouching due to the pressure.
Now where’s the
outpouching taking place?
In the esophagus, Upper
Esophageal Sphincter - UES.
Can you picture that?
Are you there?
So now, I’m eating food.
I have an diverticulum, outpouching
of the upper esophagus.
So as soon as I get my bolus down into
the esophagus, where is it going?
Into the diverticulum,
quite a bit of it.
That’s what you expect to
find on your imaging study.
There’s going to be a diverticulum in the upper portion
of esophagus where it is then accumulating food.
It’s having a hard time moving
obviously past that diverticulum,
so it’s stuck in that pouch for a long period of time.
Just like you know about your intestinal diverticulae
or diverticular disease down in the intestine.
That obviously will be faeces
accumulating in your diverticulum.
Here we have food, a bolus
accumulating in the diverticulum.
Either case, there it is
and it’s rotting.
Either the faeces, we call that faecolith,
with diverticular disease of the
intestine, or we have food that’s then
accumulating in the upper esophagus.
If it sits and it rots, tell me about
the breathe of this individual.
Yeah, halitosis, halitosis.
So here once again we will
have dysphagia, right?
We’ll have dysphagia.
with regurgitation. Halitosis.
Imagine now the diverticulum, the body wants
to get rid of the food that’s stuck in there.
Uaaagghhh, right. Regurgitation.
And treatment is surgical correction.
Surgica-… surgery, we need it because of the
weakening taking place of the upper esophagus.
Move on to hiatal hernia, step by step,
let us now dissect what this means.
What does a hiatus mean to you?
What’s hernia mean to you?
Protrusion of that structure through
the hiatus into a second compartment.
You’ve heard of abdominal hernia, you’ve heard of
inguinal hernia, you’ve heard of femoral hernia.
Here we have hiatal hernia.
What hiatus am I referring to?
Where is this hole that we’re referring
to when we talk about the GI system?
In the upper GI, in the
diaphragm, at the level of T10.
What hiatus do you find
at T10 of the vertebra?
The esophageal… esophageal
What if also, the age of this patient here,
I’m going to be very clear, pay attention.
We have an adult. We have an adult.
Why not a child?
Completely different, different,
different steps of management.
Is that clear?
Why? I’ll get to that.
At this point, I want you to think of, maybe a 35 year old
male, and the patient says, “Hey Doc, I’m having heartburn."
And upon imaging, you find that there is the fundus of the stomach that’s,
herniating into the thoracic cavity.
The fundus of the stomach herniating
into the thoracic cavity?
T10; What sphincter of
the esophagus is at T10?
You’re going to tell me,
lower esophageal sphincter.
That lower esophageal sphincter has a heck
of a responsibility, that is to do what?
To prevent the reflux of this acid
in the stomach with a pH of 2.0
… From getting into the esophagus.
That’s a lot of responsibility.
It can’t do it all by itself.
It requires support.
And where’s the support of the lower
esophageal sphincter coming from?
The diaphragm, the diaphragm.
So now let’s say that the hole
at T10, the hiatus gets enlarged.
Now, the lower esophageal
sphincter becomes weaker.
In addition, the fundus, can you
picture the fundus of the stomach?
Might then slide into
the thoracic cavity.
There’s no doubt your patient is going to have
issues with GERD - Gastroesophageal Reflux Disease.
How prevalent is this?
40% of your patients with GERD, 40% of your patients
with GERD could have an associated hiatal hernia.
Now I’ve kept saying this, that you
want to pay attention to the age.
And I told you the patient
here was an adult.
Little bit of physiology here; So now you
have the fundus coming through the hiatus,
now there’s no way the entire stomach is
going to come into the thoracic cavity.
But at some point though, that
hiatus no matter how big it is,
as the stomach is passing through here,
it’s squeezing the stomach.
What do you know about the GI system?
Lots of blood supply, lots
of blood supply right?
The mesentery, and so on and so forth.
You’re squeezing the mesentery perhaps,
therefore, what are you creating?
Infarction, stomach over a long period of time, maybe
gangrene sets in because of increased infarction.
Or persistent infarction, weakening of
the wall, you’re at risk of rupture.
So obviously management as such, you’re
going to find your patient well in advance
before that happens, but theoretically,
make sure you know the whole story.
But that’s pretty much true
of any hernia, correct?
If you have an inguinal hernia, indirect, you have
the intestine passing through the inguinal hernia,
strangulating the intestine, infarction setting
in, gangrene setting in and then peritonitis.
Same concept but now we’re
doing the hiatal hernia -adult.
What if it was congenital?
What if it was a
congenital hiatal hernia?
How old is your patient?
A child, completely different, I told you
this is… you want to handle this differently.
Or otherwise you get
the question wrong.
If its congenital type and you have
a child in which there’s hernia
of the stomach into thoracic cavity, the child is still growing.
If the stomach gets herniated into thoracic cavity in
child, you’re worried about cardiorespiratory compromise.
Your next step of management
is ECMO, ECMO, ECMO.
What ECMO means, you pay attention to O in ECMO, you find
a way in which you are providing Oxygen to that child.
Para-esophageal hernia; so if you have a sliding type of hernia
of the hiatus type, para-esophageal means exactly that.
So next to the hiatus, you have a herniation of the
stomach, next to the gastroesophageal junction.
And here, it may then cause
bleeding or strangulation.
You need to have surgical correction.
So you have two different types
of, technically hiatal hernias.
You can have sliding type, where literally the fundus
slides through your T10 in the hiatus,
or you can have a para-esophageal,
where it is next to the gastroesophageal junction
also resulting in hernia, bleeding and strangulation.