Diverticula and Hernia

by Carlo Raj, MD

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    00:01 Let us now move on to Diverticulae and Hernia.

    00:04 We’ll first begin with diverticulum.

    00:07 So what does a diverticulum mean in general? It means an outpouching.

    00:11 There’s a weakening of that particular structure in which there is an outpouching due to the pressure.

    00:17 An outpouching.

    00:18 Now where’s the outpouching taking place? In the esophagus, Upper Esophageal Sphincter - UES.

    00:28 Can you picture that? Are you there? Good.

    00:33 So now, I’m eating food.

    00:36 I have an diverticulum, outpouching of the upper esophagus.

    00:40 So as soon as I get my bolus down into the esophagus, where is it going? Into the diverticulum, quite a bit of it.

    00:47 That’s what you expect to find on your imaging study.

    00:50 There’s going to be a diverticulum in the upper portion of esophagus where it is then accumulating food.

    00:55 Accumulating food.

    00:57 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. Upper esophagus.

    01:32 If it sits and it rots, tell me about the breathe of this individual.

    01:36 Woooohhoohooo! Yeah, halitosis, halitosis.

    01:40 Not good.

    01:41 So here once again we will have dysphagia, right? We’ll have dysphagia.

    01:45 Halitosis, associated with regurgitation. Halitosis.

    01:50 Imagine now the diverticulum, the body wants to get rid of the food that’s stuck in there.

    01:55 Uaaagghhh, right. Regurgitation.

    01:58 And treatment is surgical correction.

    02:00 Surgica-… surgery, we need it because of the weakening taking place of the upper esophagus.

    02:08 Move on to hiatal hernia, step by step, let us now dissect what this means.

    02:15 What does a hiatus mean to you? A hole.

    02:20 What’s hernia mean to you? Protrusion of that structure through the hiatus into a second compartment.

    02:28 Right? You’ve heard of abdominal hernia, you’ve heard of inguinal hernia, you’ve heard of femoral hernia.

    02:33 Here we have hiatal hernia.

    02:36 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.

    02:50 What hiatus do you find at T10 of the vertebra? The esophageal… esophageal hiatus, normally.

    02:58 What if also, the age of this patient here, I’m going to be very clear, pay attention.

    03:06 We have an adult. We have an adult. Why not a child? Completely different, different, different steps of management.

    03:16 Is that clear? Why? I’ll get to that.

    03:18 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." “Heartburn? Hmm." 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? Hiatal hernia.

    03:48 Keep going.

    03:50 T10; What sphincter of the esophagus is at T10? You’re going to tell me, lower esophageal sphincter.

    03:59 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 Holy cow! … From getting into the esophagus.

    04:16 That’s a lot of responsibility.

    04:18 It can’t do it all by itself.

    04:19 It requires support.

    04:21 And where’s the support of the lower esophageal sphincter coming from? The diaphragm, the diaphragm.

    04:27 So now let’s say that the hole at T10, the hiatus gets enlarged.

    04:34 Now, the lower esophageal sphincter becomes weaker.

    04:36 In addition, the fundus, can you picture the fundus of the stomach? Might then slide into the thoracic cavity.

    04:46 There’s no doubt your patient is going to have issues with GERD - Gastroesophageal Reflux Disease.

    04:54 How prevalent is this? Quite! 40% of your patients with GERD, 40% of your patients with GERD could have an associated hiatal hernia.

    05:04 Now I’ve kept saying this, that you want to pay attention to the age.

    05:10 And I told you the patient here was an adult.

    05:14 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.

    05:22 My goodness! 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.

    05:34 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.

    05:40 You’re squeezing the mesentery perhaps, therefore, what are you creating? You’re strangulating.

    05:47 Infarction.

    05:49 Infarction, stomach over a long period of time, maybe gangrene sets in because of increased infarction.

    05:58 Or persistent infarction, weakening of the wall, you’re at risk of rupture.

    06:05 You’re dead! 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.

    06:17 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.

    06:35 Right? Same concept but now we’re doing the hiatal hernia -adult.

    06:43 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.

    06:52 Or otherwise you get the question wrong.

    06:54 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.

    07:04 If the stomach gets herniated into thoracic cavity in child, you’re worried about cardiorespiratory compromise.

    07:11 Your next step of management is ECMO, ECMO, ECMO.

    07:15 What ECMO means, you pay attention to O in ECMO, you find a way in which you are providing Oxygen to that child.

    07:24 Para-esophageal hernia; so if you have a sliding type of hernia of the hiatus type, para-esophageal means exactly that.

    07:32 So next to the hiatus, you have a herniation of the stomach, next to the gastroesophageal junction.

    07:39 And here, it may then cause bleeding or strangulation.

    07:43 You need to have surgical correction.

    07:46 So you have two different types of, technically hiatal hernias.

    07:50 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.

    About the Lecture

    The lecture Diverticula and Hernia by Carlo Raj, MD is from the course Esophageal Disease.

    Included Quiz Questions

    1. Weakening of the mucosa of the esophagus above the upper esophageal sphincter
    2. Weakening of the mucosa of the esophagus near the lower esophageal sphincter
    3. Weakening of the submucosa near the upper end of the esophagus
    4. Weakening of the submucosa near the lower esophageal sphincter
    5. None of the above
    1. Surgical correction of the esophagus
    2. Lifestyle modification
    3. Proton pump inhibitors
    4. Antacids
    5. All of the above
    1. GERD
    2. Hiatal hernia
    3. Esophageal stricture
    4. Esophageal ring
    5. None of the above
    1. Strangulation
    2. Ulceration
    3. Inflammation
    4. Acid reflux
    5. All of the above
    1. Surgery
    2. Proton pump inhibitors
    3. Antacids
    4. Lifestyle modification
    5. Iron supplementation

    Author of lecture Diverticula and Hernia

     Carlo Raj, MD

    Carlo Raj, MD

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    Every aspect in this cotent is clearly understood
    By Dvsvb R. on 04. January 2019 for Diverticula and Hernia

    It is a nice prasentation with a prompt accuracy and clear discription