Page 162 - Medicine and Surgery

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158 Chapter 4: Gastrointestinal system

Clinical features Clinical features
Most patients are asymptomatic. Patients with a slid- Patients may present with a lump in the throat and dys-
ing hernia may present with symptoms of dyspepsia due phagiawithregurgitationofundigestedfoodsomehours
to gastro-oesophageal reflux. Para-oesophageal hernias after eating. Complications include aspiration pneumo-
may cause dyspnoea or palpitations. However 20% of nia, loss of weight and loss of appetite.
patients with para-oesophageal/mixed hernias present
acutely with acute upper gastrointestinal haemorrhage, Management
strangulation, infarction or perforation of the intra- A barium swallow will demonstrate the pouch. Divertic-
thoracic stomach. ulectomy in which the pouch is excised and the defect
repaired. Endoscopic techniques may be used in elderly
Investigations patients, with a large dependent pouch, who are unfit
Chest X-ray may reveal a gas bubble above the di- for surgery.
aphragm, diagnosis is confirmed on barium swallow
which may require a head down position or pressure ap-
pliedtotheabdomen.Endoscopycanestablishtheextent Plummer–Vinson syndrome
and severity of inflammation and exclude oesophageal Definition
carcinoma. Plummer–Vinson syndrome or Paterson–Brown–Kelly
syndrome is an unusual combination of iron deficiency
Management anaemia and dysphagia.
In sliding hernias management of symptoms is

achievedeitherwithmedicalanti-secretoryagents(see
Aetiology/pathophysiology
section on Gastro-oesophageal Reflux page 156) or
There is atrophic, inflamed mucosa in the pharynx and
fundoplication. In fundoplication (open or laparo-
the upper oesophagus with the formation of a post-
scopic) the gastric fundus is mobilised and wrapped
cricoid web. The dysphagia is thought to be due to oe-
around the lower end of the oesophagus. Increase in
sophageal spasm.
intra-gastric pressure therefore results in the closing
off of the lower oesophagus. Endoscopic techniques
Clinical features
may also be used.
Patients present with dysphagia, glossitis, koilonychia
Inpara-oesophagealherniassurgeryisindicated(infit

andirondeficiencyanaemia.Thereisahighriskofupper
patients) to reduce the risk of strangulation and other
oesophageal or pharyngeal malignancy.
life-threatening complications. Surgery consists of ex-
cisionoftheperitonealsac,reductionoftheherniaand
closure of the defect. A fundoplication is usually then Management
performed. Webs are dilated endoscopically to relieve obstruction,
iron deficiency anaemia is treated. If malignancy occurs
the prognosis is poor.
Pharyngeal pouch
Definition Achalasia
A false diverticulum arising at the junction of the oe-
sophagus and the pharynx. Definition
Achalasia is a disordered contraction of the oesophagus
Aetiology/pathophysiology of neuromuscular origin.
Inco-ordinationbetweenthecontractionofthepharynx
andrelaxationoftheupperoesophagealsphinctercauses Aetiology
the pharyngeal mucosa to herniate posteriorly between Degeneration is seen in the vagus nerve associated with
the upper and lower fibres of the inferior constrictor adecrease in ganglionic cells in the Auerbach’s nerve
muscle (Killian’s dehiscence). plexus within the oesophageal wall. Chagas’ disease in