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Hiatal Hernia Presentators Day, Date #u$er%isor : Doni Fitra Yogi (090100110) Joanita Kurniadi (090100122) : Monday, 8th O to!er 201" : dr& Pertin #ianturi, #$&'(K) CHAPTER 1 INTRODUCTION 1.1 Background (nder nor)a* ir u)stan es, the sto)a h is he*d in $osition !y the *iga)ents& gastro$hreni , gastrohe$ati , gastroduodena*, and gastros$*eni the dia$hrag)ati

Further)ore, the $hrenoeso$hagea* )e)!rane he*$s to $re%ent herniation through hiatus& +his )e)!rane atta hes near the s,ua)o o*u)nar -un tion and e.tends a$$ro.i)ate*y 1 ) a!o%e this& During s/a**o/ing and *ongitudina* eso$hagea* )us *e ontra tion, there is 0$hysio*ogi a*1 herniation o2 the gastri ardia through the dia$hrag)ati hiatus& +he $hrenoeso$hagea* )e)!rane has a re oi* a tion to $u** the s,ua)o o*u)nar -un tion !a 3 into its nor)a* anato)i a* $osition& 4hen these )e hanis)s are de2e ti%e, true herniation an de%e*o$& ' hiatal hernia is a herniation o2 $art o2 the sto)a h into the thora i a%ity through the eso$hagea* hiatus in the dia$hrag)& ' sliding hiatal hernia is one in /hi h the gastroeso$hagea* -un tion and 2undus o2 the sto)a h s*ide u$/ard& ' s*iding hernia )ay resu*t 2ro) /ea3ening o2 the an hors o2 the gastroeso$hagea* -un tion to the dia$hrag), 2ro) *ongitudina* ontra tion o2 the eso$hagus, or 2ro) in reased intraa!do)ina* $ressure& #)a** s*iding hernias an !e de)onstrated o))on*y during !ariu) studies i2 intraa!do)ina* $ressure is in reased& 5n iden e in reases /ith age6 in indi%idua*s in the si.th de ade o2 *i2e, the $re%a*en e o2 su h hernias is 7809& #)a** s*iding hiata* hernias a*one $ro!a!*y $rodu e no sy)$to)s !ut an ontri!ute to re2*u. eso$hagitis&

' paraesophageal hernia is one in /hi h the eso$hagogastri -un tion re)ains 2i.ed in its nor)a* *o ation and a $ou h o2 sto)a h is herniated !eside the gastroeso$hagea* -un tion through the eso$hagea* hiatus& ' $araeso$hagea* or )i.ed $araeso$hagea* and s*iding hernia )ay !e o)e in ar erated and strangu*ated, *eading to a ute hest $ain, dys$hagia, and a )ediastina* )ass and re,uiring surgery& ' herniated gastri $ou h )ay ause dys$hagia, gastritis, u* eration, or hroni !*ood *oss& :arge $araeso$hagea* hernias shou*d !e surgi a**y re$aired& ;iata* hernias are )ore o))on in 4estern ontries& +he 2re,uen y o2 hiatus hernia in reases /ith age, 2ro) 10 9 in $atients younger than <0 years to =09 in $atients o*der than =0 years& >ur3itt et a* suggest that the 4estern, 2i!er de$*eted diet *eads to a stase o2 hroni onsti$ation and straning during !o/e* )o%e)ent, /hi h ou*d e.$*ain '*though the e.isten e o2 hiata* hernia has !een des ri!ed in ear*ier )edi a* *iterature, it has o)e under s rutiny on*y in the *ast entury or so !e ause o2 its asso iation /ith gastroeso$hagea* re2*u. disease (?@AD) and its o)$*i ations& +here is a*so an asso iation !et/een o!esity and $resen e o2 hiata* hernia& >y 2ar, )ost hiata* hernias are asy)$to)ati %o*%u*us or strangu*ation, )ay $resent a ute*y& 1.2 Ob ecti!e +he ai) o2 this study is to e.$*ore )ore a!out the theoriti a* as$e ts on ;iata* ;ernia, and to integrate the theory and a$$*i ation o2 ;iata* ;ernia ases in dai*y *i2e& and are dis o%ered in identa**y& On rare o asion, a *i2eBthreatening o)$*i ation, su h as gastri the higher in iden e o2 this ondition in 4estern ountries&

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CHAPTER 2 "ITERATURE RE#IE$ 2.1 De%inition ' hiatal hernia is a herniation o2 $art o2 the sto)a h into the thora i through the eso$hagea* hiatus in the dia$hrag)& 2.2 Cla&&i%ication a. 'liding (iatal (ernia 5n a s*iding hiata* hernia, $art o2 the sto)a h )o%es through the dia$hrag) so that it $ositioned outside o2 the a!do)en and in the hest& +he *o/er eso$hagea* s$hin ter (:@#) o2ten )o%es u$ a!o%e its nor)a* *o ation in the o$ening o2 the dia$hrag)& #*iding hiata* hernia is !y 2ar the )ost o))on ty$e o2 hiata* hernia, and other then its asso iation /ith a id re2*u., usua**y does not re,uire re$air e. e$t in on-un tion /ith antiBre2*u. surgery& a%ity

b. Parae&o)(ageal (ernia and *i+ed Hernia 5n a $araeso$hagea* hernia, the sto)a h !u*ges u$ through the o$ening in the dia$hrag) (hiatus) a*ongside the eso$hagus (u$sideBdo/n sto)a h)& +he :@# re)ains in its nor)a* *o ation inside the o$ening o2 the dia$hrag)& +his ty$e o2

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hernia )ost o))on*y o urs /hen there is a *arge o$ening in the dia$hrag) ne.t to the eso$hagus& +he sto)a h and, rare*y, other a!do)ina* organs (su h as the intestine, s$*een, and o*on) )ay a*so !u*ge into the hest in a $araeso$hagea* hernia& 5n a )i.ed hiata* hernia, the :@# is a!o%e the dia$hrag) as in a s*iding hiata* hernia and the sto)a h is a*ongside the eso$hagus as in a $araeso$hagea* hiata* hernia& Paraeso$hagea* and )i.ed hiata* hernias o2ten ha%e no sy)$to)s or on*y )ini)a* sy)$to)s& #y)$to)s )ay in *ude %ague, nons$e i2i a!do)ina* o)$*aints su h as 2ee*ing 2u** a2ter a )ea* and indigestion& Patients )ay a*so ha%e %o)iting or hest $ain& O asiona**y $atients ha%e )ini)a* sy)$to)s !ut ha%e ane)ia that is di22i u*t to e.$*ain& +his is due to %ery s*o/ *oss o2 !*ood 2ro) irritation o2 the sto)a h at the ne 3 o2 the hernia& 52 not treated, the Paraeso$hagea* and )i.ed hernias an gro/& +his an resu*t in t/isting (%o*%u*us) o2 the sto)a h ($ossi!*y *eading to gangrene), /hi h re,uires e)ergen y surgi a* treat)ent& >e ause o2 the ris3 in%o*%ed in e)ergen y treat)ent, it genera**y is re o))ended that a** $eo$*e /ith these ty$es o2 hernias undergo surgery regard*ess o2 the sy)$to)s& C

2., Cau&e& Mus *e /ea3ening and *oss o2 e*asti ity as $eo$*e age is thought to $redis$ose to hiatus hernia, !ased on the in reasing $re%a*en e in o*der $eo$*e& 4ith de reasing tissue e*asti ity, the gastri )us *e tone around the dia$hrag)ati $atu*ous& ;iata* hernias are )ore o))on in /o)en& +his )ay re*ate to the intraB a!do)ina* 2or es e.erted in $regnan y& Fi!erBde$*eted diet *eads to a state o2 hroni !o/e* )o%e)ent& O!esity $redis$oses to hiatus hernia !e ause o2 in reased a!do)ina* $ressure& Donditions su h as hroni eso$hagitis )ay ause shortening o2 the eso$hagus !y ausing 2i!rosis o2 the *ongitudina* )us *es and, there2ore, $redis$ose to hiata* hernia& ;o/e%er, /hi h o)es 2irst, the hiata* hernia /orsening the re2*u. or the re2*u.Bindu ed shortening o2 the eso$hagus, re)ains un3no/n& 2.- Pat(o)(.&iolog. +he eso$hagus $asses through the dia$hrag)ati hiatus in the rura* $art o2 the dia$hrag) to rea h the sto)a h& +he dia$hrag)ati hiatus itse*2 is a$$ro.i)ate*y 2 ) in *ength and hie2*y onsists o2 )us u*otendinous s*i$s o2 the right and *e2t dia$hrag)ati rura arising 2ro) either side o2 the s$ine and $assing around the eso$hagus !e2ore inserting into the entra* tendon o2 the dia$hrag)& +he siEe o2 the hiatus is not 2i.ed, !ut narro/s /hene%er intraBa!do)ina* $ressure rises, su h as /hen *i2ting /eights or oughing& 1 +he *o/er eso$hagea* s$hin ter (:@#) is an area o2 s)ooth )us *e a$$ro.i)ate*y 2&CB<&C ) in *ength& +he u$$er $art o2 the s$hin ter nor)a**y *ies /ithin the dia$hrag)ati hiatus, /hi*e the *o/er se tion nor)a**y is intraB a!do)ina*& 't this *e%e*, the %is era* $eritoneu) and the $hrenoeso$hagea* onsti$ation and straining during ardia )ay not return to its nor)a* o$ening a*so )ay )a3e it )ore $osition !e*o/ the dia$hrag)ati hiatus 2o**o/ing a nor)a* s/a**o/& :oss o2

*iga)ent o%er the eso$hagus& +he $hrenoeso$hagea* *iga)ent is a 2i!rous *ayer o2 onne ti%e tissue arising 2ro) the rura, and it )aintains the :@# /ithin the a!do)ina* a%ity& +he 'Bring is an indentation so)eti)es seen on !ariu) studies, and it )ar3s the u$$er $art o2 the :@#& Just !e*o/ this is a s*ight*y di*ated $art o2 the eso$hagus, 2or)ing the %esti!u*e& ' se ond ring, the >Bring, )ay !e seen -ust dista* to the %esti!u*e, and it a$$ro.i)ates the FB*ine or s,ua)o o*u)nar -un tion& +he $resen e o2 a >Bring on2ir)s the diagnosis o2 a hiata* hernia& O asiona**y, the >Bring a*so is a**ed the # hatE3i ring& 'ny sudden in rease in intraBa!do)ina* $ressure a*so a ts on the $ortion o2 the :@# !e*o/ the dia$hrag) to in rease the s$hin ter $ressure& 'n a ute ang*e, the ang*e o2 ;is, is 2or)ed !et/een the ardia o2 the sto)a h and the dista* eso$hagus and 2un tions as a 2*a$ at the gastroeso$hagea* -un tion and he*$s $re%ent re2*u. o2 gastri ontents into the eso$hagus (see the i)age !e*o/)&

;iata* hernia& Figure 1 sho/s the nor)a* re*ationshi$ o2 the gastroeso$hagea* -un tion, sto)a h, eso$hagus, and dia$hrag)& Figure 2 sho/s a s*iding hiata* hernia /here the sto)a h i))ediate*y !e*o/ the gastroeso$hagea* -un tion is seen to $ro*a$se through the dia$hrag)ati hiatus into the hest& Figure " sho/s a $araeso$hagea* hernia in /hi h the ardia or 2undus o2 the sto)a h $ro*a$ses through the dia$hrag)ati hiatus, *ea%ing the gastroeso$hagea* -un tion /ithin the eso$hagea* a%ity& +he gastroeso$hagea* -un tion a ts as a !arrier to $re%ent re2*u. o2 ontents 2ro) the sto)a h into the eso$hagus !y a o)!ination o2 )e hanis)s 2or)ing the antire2*u. !arrier& +he dia$hrag)ati o)$onents o2 this !arrier in *ude the rura, the :@# !ase*ine $ressure and intraBa!do)ina* seg)ent, and

the ang*e o2 ;is& +he $resen e o2 a hiata* hernia o)$ro)ises this re2*u. !arrier not on*y in ter)s o2 redu ed :@# $ressure !ut a*so redu ed eso$hagea* a id *earan e& Patients /ith hiata* hernias a*so ha%e *onger transient :@# re*a.ation e$isodes $arti u*ar*y at night ti)e& +hese 2a tors in rease the eso$hagea* )u osa a id onta t ti)e $redis$osing to eso$hagitis and re*ated o)$*i ations& 2./ Diagno&i& a. Hi&tor. ;iata* hernias are re*ati%e*y o))on and, in the)se*%es, do not ause sy)$to)s& For this reason, )ost $eo$*e /ith hiata* hernias are asy)$to)ati & ;iata* hernias )ay $redis$ose to re2*u. or /orsen e.isting re2*u. in a )inority o2 indi%idua*s& Physi ians shou*d resist the te)$tation to *a!e* hiata* hernia as a disease& Patients an ha%e re2*u. /ithout a de)onstra!*e hiata* hernia& 4hen a hernia is $resent in a $atient /ith sy)$to)ati ?@AD, su h as heart!urn, regurtation, 2re,uent !e* hing, and hest $ain& +he hernia )ay /orsen sy)$to)s 2or se%era* reasons, in *uding the hiata* hernia a ting as a 2*uid tra$ 2or gastri re2*u. and in reasing the a id onta t ti)e in the eso$hagus& 5n addition, /ith a hiata* hernia, e$isodes o2 transient re*a.ation o2 the :@# are )ore 2re,uent and the *ength o2 the highB$ressure Eone is redu ed& +he )ain sy)$to)s o2 a s*iding hiata* hernia are those asso iated /ith re2*u. and its o)$*i ations& b. P(.&ical e+a0ination +he $hysi a* e.a)ination usua**y is unhe*$2u*& Dertain onditions $redis$ose to the de%e*o$)ent o2 hiatus hernia& +hese in *ude o!esity, $regnan y, and as ites& c. "aborator. 'tudie& +he ty$i a* reasons 2or e%a*uation are sy)$to)s o2 ?@AD or a hest radiogra$h suggesting a $araeso$hagea* hernia& d. I0aging 'tudie& >ariu) u$$er gastrointestina* series

'*though a hest radiogra$h )ay re%ea* a *arge hiata* hernia (Figure 2), and )any in identa**y diagnosed hiata* hernias are dis o%ered in this )anner, a !ariu) study o2 the eso$hagus he*$s esta!*ish the diagnosis /ith greater a ura y (Figure ")&

Figure 2& 'ntero$osterior (*e2t and *atera* %ie/s (right) on a hest radiogra$h sho/ing a *arge hiata* hernia&

Figure "& >ariu) study sho/s a s*iding hiata* hernia: +he gastri 2o*ds an !e seen e.tending a!o%e the dia$hrag)& +y$i a* 2indings in *ude an out$ou hing o2 !ariu) at the *o/er end o2 the eso$hagus, a /ide hiatus through /hi h gastri 2o*ds are seen in ontinuu) /ith those in the sto)a h, and, o asiona**y, 2ree re2*u. o2 !ariu)& ' !ariu) study he*$s distinguish a s*iding 2ro) a $araeso$hagea* hernia (see the i)ages !e*o/)&

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Figure <& ' $araeso$hagea* hernia is seen on an u$$er gastrointestina* series& Gote that the gastroeso$hagea* -un tion re)ains !e*o/ the dia$hrag)&

Figure C& Paraeso$hagea* hernia is seen on !ariu) u$$er gastrointestina* series& +he )u osa* 2o*ds are seen going u$ into the hest, ne.t to the eso$hagus&

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Figure 8& >ariu) radiogra$h %ie/ o2 a *arge $araeso$hagea* hernia& 5n rare ases, the entire sto)a h )ay herniate into the hest& (Figure =)

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Figure =& ' *arge $araeso$hagea* hernia in /hi h the entire sto)a h is seen in the hest a%ity& @ndos o$y ;iata* hernia is diagnosed easi*y using u$$er gastrointestina* endos o$y& +he diagnosis o2 a hiata* hernia a tua**y is in identa*, and endos o$y is used to diagnose o)$*i ations su h as erosi%e eso$hagitis, u* ers in the hiata* hernia, >arrett eso$hagus, or tu)or& ' hiata* hernia is on2ir)ed /hen the endos o$e is a!out to enter the sto)a h or on retrograde %ie/ on e inside the sto)a h (see the i)age !e*o/)& 52 any dou!t re)ains, the $atient )ay !e as3ed to sni22 through the nose, /hi h auses the dia$hrag)ati rura to a$$ro.i)ate, seen as a $in h, *osing the *u)en&

Figure 8& ' retrograde %ie/ o2 a hiata* hernia seen at endos o$y sho/s the gastri 2o*ds to the *e2t o2 the s o$e sha2t e.tending u$ into the hernia& @ndos o$y a*so $er)its !io$sy o2 any a!nor)a* or sus$i ious area& @so$hagea* )ano)etry has a *o/ sensiti%ity 2or diagnosing hiata* hernia, as o)$ared to endos o$y, and is there2ore not a$$ro$riate in he*$ing to esta!*ish a diagnosis&

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2.1 Di%%erential Diagno&e 'ngina Pe toris ?@AD 5s he)i heart disease >i*iary o*i #to)a h an er (* er 2.2 Treat0ent a. *edical Care 4hen hiata* hernias are sy)$to)ati , a id re2*u. usua**y $rodu es the sy)$to)s& 52 the hernia itse*2 is ausing hest dis o)2ort or other sy)$to)s, surgery )ay !e ne essary&

4hen sy)$to)s are due to ?@AD, the goa*s o2 treat)ent in *ude $re%ention o2 re2*u. o2 gastri ontents, i)$ro%ed eso$hagea* *earan e, and redu tion in a id $rodu tion& +his is a hie%ed in the )a-ority o2 $atients !y a o)!ination o2 the 2o**o/ing:
o o o

Modi2ying *i2esty*e 2a tors Geutra*iEing a id or inhi!iting a id $rodu tion @nhan ing eso$hagea* and gastri )oti*ity ause iron de2i ien y ane)ia regard*ess o2

:arge hiata* hernias )ay

/hether Da)eron u* ers are $resent& +his ane)ia res$onds /e** to PP5 thera$y /ith surgery o22ering no *ear ad%antage o%er )edi a* thera$y& 10 b. 'urgical Care +he goa* o2 surgery is to re)o%e the hernia sa and *ose the a!nor)a**y /ide eso$hagea* hiatus& #urgery is ne essary on*y in the )inority o2 $atients /ith o)$*i ations o2 ?@AD des$ite aggressi%e treat)ent /ith $roton $u)$ inhi!itors (PP5s)& >e ause on*y a )inority o2 $atients /ith hiata* hernia ha%e any $ro!*e)s,

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this re$resents a %ery s)a** $ro$ortion o2 $atients /ith s*iding hiata* hernia6 )ost $atients /ith $ro!*e)s are )anaged )edi a**y& >y 2ar, the )a-ority o2 $atients /ho /ou*d ha%e undergone surgery in the $ast are )anaged su ess2u**y today /ith PP5s& ;o/e%er, young $atients /ith se%ere or re urrent o)$*i ations o2 ?@AD, su h as stri tures, u* ers, and !*eeding, /ho annot a22ord *i2e*ong PP5 treat)ent or /ou*d $re2er to a%oid ta3ing )edi ations *ong ter), )ay !e surgi a* andidates& 'nother grou$ o2 $atients /ho are surgi a* andidates are those /ith $u*)onary o)$*i ations, in $arti u*ar, asth)a, re urrent as$iration $neu)onia, hroni ough, or hoarseness *in3ed to re2*u. disease& Most $atients /ith a $araeso$hagea* hernia re)ain asy)$to)ati & 5n this ty$e o2 hernia, sy)$to)s 2ro) a id re2*u. usua**y do not o ur& 5nstead, the )ost o))on sy)$to) is e$igastri or su!sterna* $ain& #o)e $atients o)$*ain o2 su!sterna* 2u**ness, nausea, and dys$hagia& ' signi2i ant $ro$ortion o2 $atients /ith this ty$e o2 hernia de%e*o$ in ar eration o2 the hernia and $ossi!*e gastri %o*%u*us, /hi h an *ead to $er2oration& 52 $er2oration o urs, the )orta*ity rate is high& >e ause o2 this, )any surgeons ad%ise e*e ti%e re$air /hen the diagnosis is )ade& ' $atient /ith a *arge hiata* hernia )ay e.$erien e %ague inter)ittent hest dis o)2ort or $ain& +he $araeso$hagea* hernia )ay strangu*ate and 2re,uent*y is o$erated on $ro$hy*a ti a**y to $re%ent this o)$*i ation& Paraeso$hagea* hernias )ay $resent in in2ants or adu*ts as a $otentia**y *i2eBthreatening o)$*i ation o2 strangu*ation, and $ro)$t surgi a* re$air is 3ey& 4hen 2ound in asy)$to)ati indi%idua*s, *a$aros o$i re$air is o2ten underta3en, /ith *arge de2e ts in the dia$hrag) !eing *osed /ith )esh& +hree )a-or ty$es o2 surgi a* $ro edures orre t gastroeso$hagea* re2*u. and re$air the hernia in the $ro ess& +hey an !e $er2or)ed !y o$en *a$aroto)y or /ith *a$aros o$i a$$roa hes, /hi h urrent*y are !eing e)$*oyed )ore 2re,uent*y& +hese $ro edures o22er re*ie2 o2 sy)$to)s in 80B909 o2 $atients&

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5n )ost ases, the $ro edure o2 hoi e is the one /ith /hi h the surgeon is )ost 2a)i*iar& +hese $ro edures arry *o/ )orta*ity and )or!idity rates, *o/er than 1CB 209& DeMeester et a* 2ound the Gissen $ro edure su$erior to the >e*sey and ;i** re$airs /ith regard to sy)$to) re*ie2 and $re%ention o2 re2*u. $osto$erati%e*y (as -udged !y $; )onitoring)& ?ood *ongBter) resu*ts ha%e !een re$orted 2or antire2*u. surgery, /ith ade,uate ontro* o2 re2*u. in the range o2 809 at 10 years& Gissen Fundo$*i ation +he Gissen 2undo$*i ation $er2or)ed *a$aros o$i a**y has gained $o$u*arity !e ause o2 its *o/er )or!idity and shorter hos$ita* stay o)$ared to the o$en $ro edure $er2or)ed $re%ious*y& '*though a re*ati%e*y high in iden e o2 $osto$erati%e o)$*i ations, su h as dys$hagia and gas !*oating, are re$orted, DeMeester and Peters1< ha%e sho/n that $*a ing a *arger !ougie in the eso$hagus during this $ro edure, a*ong /ith a shorter /ra$ and )ore o)$*ete )o!i*iEation o2 the sto)a h, ha%e )ar3ed*y redu ed $osto$erati%e dia$hrag)ati hiatus a*so is re$aired& ' transthora i a$$roa h )ay !e used in $atients /ho ha%e had a $re%ious Gissen /ra$ or those /ho ha%e an irredu i!*e hernia& +he +ou$et $ro edure is a %ariant o2 the Gissen /ra$ and in%o*%es a 180H /ra$ in an atte)$t to *essen the *i3e*ihood o2 $osto$erati%e dys$hagia& >e*sey (Mar3 5I) Fundo$*i ation +his o$eration in%o*%es a 2=0H /ra$ in an atte)$t to redu e the in iden e o2 gas !*oating and $osto$erati%e dys$hagia& 5t a*so is $re2erred /hen )ini)a* eso$hagea* dys)oti*ity is sus$e ted& +o o)$*ete this o$eration, the *e2t and right rura o2 the dia$hrag) are a$$ro.i)ated& ;i** Ae$air o)$*i ations&+his $ro edure in%o*%es a "80H 2undi /ra$ around the gastroeso$hagea* -un tion& +he

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5n this $ro edure, the ardia o2 the sto)a h is an hored to the $osterior a!do)ina* areas, su h as the )edia* ar uate *iga)ent& +his a*so has the e22e t o2 aug)enting the ang*e o2 ;is and thus strengthening the antire2*u. )e hanis)& #o)e surgeons then ta 3 the sto)a h do/n in the a!do)en to $re%ent it 2ro) )igrating u$/ards again, or, they $er2or) a te)$orary gastrosto)y to he*$ de o)$ress the sto)a h and an hor it in $*a e in the a!do)ina* a%ity& c c. . Diet

'n a$$ro$riate diet )aintains an idea* !ody )ass inde.& O!esity $redis$oses to re2*u. disease&

>ur3itt et a* suggest that the 4estern, 2i!erBde$*eted diet *eads to a state o2 hroni onsti$ation and straining during !o/e* )o%e)ent, /hi h /ou*d e.$*ain the higher in iden e o2 this ondition in 4estern ountries&

2.3 Pat(ogene&i& 4ERD t(at cau&ed b. Hiatal Hernia Patho*ogi re2*u. o2 gastri ontents o urs /hen the re2*u.ate o%er o)es the antire2*u. !arriers o2 the gastroeso$hagea* -un tion, ty$i a**y in a $ostB$randia* state& +he antire2*u. !arrier o2 the gastroeso$hagea* -un tion is anato)i a**y and $hysio*ogi a**y o)$*e. and %u*nera!*e to a nu)!er o2 $otentia* )e hanis)s o2 re2*u.& +he $ri)ary antire2*u. )e hanis) is the :@#, a seg)ent o2 s)ooth )us *e in the *o/er eso$hagus that is hroni a**y ontra ted to )aintain a $ressure that is a$$ro.i)ate*y 1C )) ;g a!o%e intragastri $ressure& +he t/o )ain $atterns o2 :@# dys2un tion are (1) a hy$otensi%e :@# and (2) $atho*ogi transient :@# re*a.ations& 'nato)i disru$tion o2 the gastroeso$hagea* -un tion, o))on*y asso iated /ith a hiata* hernia, ontri!utes to the $athogenesis o2 re2*u. disease !y i)$airing :@# 2un tion& ' *arge hiata* hernia $redis$oses to transient :@# re*a.ations and in reases the ris3 o2 de%e*o$ing eso$hagitis& +ransient :@# re*a.ations a ount 2or the )a-ority o2 re2*u. e%ents in indi%idua*s /ith nor)a* :@# $ressure and *ini a**y )i*d re2*u. disease& Dhroni a**y *o/ :@#

1=

$ressure is the $redo)inant ?@AD )e hanis) in $atients /ith se%ere re2*u. disease, su h as in $atients /ith s *eroder)a& ?astri 2a tors an $*ay a signi2i ant ro*e in $rodu ing ?@AD& ?astri 2a tors that $ro)ote ?@AD in *ude in reased gastri %o*u)e a2ter )ea*s, or drug indu ed& in reased gastri $ressure due to o!esity, re u)!en y a2ter )ea*s, and de*ayed gastri e)$tying or gastro$aresis, /hi h an !e idio$athi 5n reased gastri distention an ause an in rease in transient :@# re*a.ations and the %o*u)e o2 re2*u.ate, $arti u*ar*y in ?@AD $atients /ith *arge hiata* hernias& De*ayed gastri e)$tying, or gastro$aresis, )ay !e $resent in a$$ro.i)ate*y 1C9 o2 $atients /ith ?@AD and is 2re,uent*y underdiagnosed& Other 2a tors that de rease :@# $ressure and ontri!ute to ?@AD are )edi ations, *i2esty*e !eha%iors, and the ingestion o2 ertain 2oods& Dertain )edi ines an e.a er!ate ?@AD !y *o/ering :@# $ressure6 others an ause eso$hagitis !y dire t )u osa* in-ury (+a!*e 1)& Dertain 2oods, !e%erages, and !eha%iors /i** ause heart!urn !y redu ing :@# $ressure (+a!*e 1)& Fatty 2oods, $e$$er)int, ho o*ate, a22einated !e%erages, a* oho* and s)o3ing an a** de rease :@# $ressure& Table 1 5actor& t(at can )reci)itate or e+acerbate 4ERD &.0)to0& 5ood& Da22eine Dho o*ate Pe$$er)int '* oho* (red /ine $; J ",2C) Dar!onated !e%erages ( o*a $; J 2,=C) Ditrus 2ruits (orange -ui e $; J ",2C) +o)atoB!ased $rodu ts (to)ato -ui e $; J ",2C) "i%e&t.le %actor& 4eight gain #)o3ing @ating $rior to re u)!en y

2.6 Co0)lication& Dhroni heart!urn and in2*a))ation o2 the *o/er oeso$hagus, a**ed re2*u. oeso$hagitis&

18

'ne)ia due to hroni !*eeding 2ro) the *o/er oeso$hagus& # arring and narro/ing o2 the *o/er oeso$hagus ausing di22i u*ty in s/a**o/ing& 4hi*e s*ee$ing, sto)a h se retions an see$ u$ the oeso$hagus and into thr *ungs ausing hroni ough, /heeEing, and e%en $neu)onia&

19

CHAPTER III CA'E REPORT YG, 2e)a*e, " year 9 )onths, a)e to A#;'M Medan on #e$te)!er, 1Cth, 201" /ith )ain o)$*aint he)ate)esis sin e this e%ening !e2ore ad)ission, 2re,uen y on e a day, %o*u)e )ore or *ess K g*ass (a,ua)& ;istory o2 he)ate)esis /as 2ound sin e one year ago $ost hernia surgery & Patient o)$*aint seiEure& 5t /as ha$$ened sin e si. hours !e2ore a)e into the hos$ita*, the seiEure /as genera*iEed at /ho*e !ody& +he seiEure *ast 2or C )ins /ith 2re,uen y 1 ti)es& '2ter the seiEure the $atient /as ons ious& ;istory o2 re urent seiEures /as not 2ound&& #eiEure /as not $re eded !y 2e%er& Fe%er /as 2ound sin e one /ee3 ago, 2e%er /ent u$ and do/n, 2e%er su!sided /ith onsu)$tion o2 drug ($ara eta)o*)& ;istory o2 re urrent 2e%er /as not 2ound& Gausea /as 2ound sin e one /ee3 ago& ;istory o2 de2e ating and urinating /as 2ound nor)a**y& Fre,uen y o2 de2e ation < ti)es a day sin e this e%ening& ;istory o2 %o)iting /as not 2ound& ;istory o2 s$ontan !*eeding /as not 2ound& ;istory o2 !irth : nor)a*, assited !y do tor& Dried instant*y a2ter !irth, !irth /eight 2=00 3g& ;istory o2 $re%ious i**ness : none ;istory o2 $re%ious )edi ations : $atient has ta3en GaD* 0,9 9 , in-e tion

+ransa)in, in-e tion Aanitidin, in-e tion De2tia.one& ;istory o2 2eeding:

0B2 )onths on*y !reast 2eeding 2B8 )onths: !reast 2eeding L 2or)u*a )i*3& 8 )onthsB2 years: !reast 2eeding L 2or)u*a )i*3 L $orridge& +his ti)e: 2a)i*y 2ood

20

;istory o2 i))uniEation : o)$*ete ;istory o2 so ia* : )idd*e ;istory o2 e ono)y : )idd*e P(.&ical E+a0ination Pre&en& &tatu& #ensoriu) ;eart Aate Aes$iratory Aate >*ood $ressure : Do)$os Mentis : 1"8 !$) : "2 !$) : 110M=0 ));g

>ody te)$erature : "=,8oD& Nutritional 'tatu& >ody /eight >ody height : 11 3gs : 92 )

;ead Dir u)2eren e : <8 ) "ocali7ed &tatu& 1& 2& ;ead @ye @ar : Gor)o e$ha*, no de2or)ities or any sign o2 trau)a& : :ight re2*e.es (LML), iso hori $u$i*, on-un ti%a $a*$e!ra in2erior nor)a*, i teri /as not 2ound : nor)a* a$$erean e Gose : G?+ inserted /ith red !ro/nish o*or& Mouth : no sianosis "& <& Ge 3 : no *y)$h node en*arge)ent, no ne 3 rigidity ;A: 1"8 !$), regu*er, no )ur)ur& AA: "2 !$), regu*ar, no ra 3*es& C& '!do)en : #oe$e*&*i%erMs$*eenMrena* : not $a*$a!*e& Perista*ti /as nor)a*& +hora. : #y))etri a* 2usi2or)is& e$igastria* retra tion (B)

21

8& =&

@.tre)ities : Pu*se 1"8 !$), regu*ar, ade,uate $ressure and %o*u)e, /ar) a ra*, DA+N"1& (rogenita* : Fe)a*e , nor)a* in a$$earan e&

Di%%erential Diagno&i& B B B #i)$*e Fe!ri*e #eiEure L ?5 !*eeding #i)$*e Fe!ri*e #eiEure L ?@AD #i)$*e Fe!ri*e #eiEure L ?5 !*eeding B 5IFD DC9 GaD* 0,<C 9 "0 gttMi )i3ro

$orking Diagno&i& Treat0ent

Planning B Do)$*ete >*ood Dount

22

5O""O$ UP 'e)te0ber8 11t( 291, :1&t da.; '< ;e)ate)esis(B), #eiEure(B) O< #ens: DM , +e)$: "=,2 oD ;ead @ye : *ight re2*e.es (LML), iso hori $u$i*, on-un ti%a $a*$e!ra in2erior nor)a*, +hora. i teri /as not 2ound , ear : nor)a* a$$earan e, )outh : no sianosis, nose: O2 nasa* 3anu* inserted, G?+ inserted /ith !ro/nish o*or&& #y))etri a* 2usi2or)&& ;A: 12< !$), regu*er, no )ur)ur& AA: 28 !$),

regu*ar, no ra 3*es& '!do)en #oe$e*& $erista*ti (L) nor)a*& *i%erMs$*eenMrena*: not $a*$a!*e& @.tre)ities Pu*se 12< !$), regu*ar, ade,uate $ressure and %o*u)e, /ar) a ra*, DA+ N "1, !ruise /as 2ound at !oth *o/er e.tre)ities&

A< P#M>' e DD Bu* us $e$ti u) L si)$*e 2e!ri*e seiEure Bgastritis P: Manage)ent = = = = = B B B 5IFD D# GaD* 0,<C9 "0 gttM5 )i ro Diet F =C CC M 2 hours /ith )inera* )i. 1,1 through G?+ 5n-& De2tria.one C00 )g M 12 hrs M 5I 5n-& Aanitidin 12 )gM 12 hrs M 5I 5n-& +ransa)in 1C0 )g M 8 hrs M 5I Para eta)o* " . th 5 M G?+ Fasting diet #$oo*ing /ith GaD* 0,9 9

2"

Plan < B Dhe 3 o2 DAP, and Pro a* itonin B :F+ B (rine and Fea es +est B Donsu*t to ?astroenterohe$ato*ogi De$art)ent 'e)te0ber8 12t( 291, :2nd da.; '< Fe%er (L), #to)atitis (L), >*eeding on G?+ (L), seiEure (B) O< #ens: DM , +e)$: "=,2oD, >ody /eight: C 3g >4M>: N B"#D ;ead, eye : :ight re2*e.es(LML), iso hori $u$i*, on-un ti%a $a*$e!ra in2erior nor)a*& earM)outh: nor)a*, nose : G?+ inserted +hora. : #y))etri a* 2usi2or)is& ;A : 100 !$), regu*er, no )ur)ur& AA : 28 !$), regu*ar, no ra 3*es& '!do)en : #oe$e*& Perista*ti (L) nor)a*& *i%erMs$*eenMrena*: not $a*$a!*e& @.tre)ities :Pu*se 100 !$), regu*ar, ade,uate $ressure and %o*u)e, /ar) a ra*, DA+ N "1 A< P#M>' e DD Bu* us $e$ti u) L si)$*e 2e!ri*e seiEure Bgastritis P< Manage)ent: = = = = = = = = 5IFD D# GaD* 0,<C9 "0 gttM5 )i ro Diet F =C CC M 2 hours /ith )inera* )i. 1,1 through G?+ 5n-& De2tria.one C00 )g M 12 hrs M 5I 5n-& Aanitidin 12 )gM 12 hrs M 5I 5n-& +ransa)in 1C0 )g M 8 hrs M 5I Para eta)o* " . th 5 M G?+ Diet )i*3 100 M" hrs %ia G?+ #$oo*ing /ith GaD* 0,9 9 BB BBB

Plan < =

2<

'e)te0ber8 13t( 291, :,rd da.; '< Fe%er(B), >*eeding 2ro) G?+(B) O< #ens: DM, te)$: "=oD, ;A : 10< !$), AA : 28 !$) ;ead, eye : :ight re2*e.es (LML), iso hori $u$i*, on-un ti%a $a*$e!ra in2erior nor)a*, earM)outh: nor)a*, nose : G?+ inserted +hora. : #y))etri a* 2usi2or)& ;A : 10< !$), regu*er, )ur)ur (B)& AA : 28 !$), regu*er& Go ra 3*es, no retra tion,& '!do)en: #oe$e*& $erista*ti (L) nor)a*& *i%erMs$*eenMrena* : not $a*$a!*e& @.tre)ities : Pu*se 10< !$), regu*ar, ade,uate $ressure and %o*u)e, /ar) a ra*, DA+ N "1 A< P#M>' e DD Bu* us $e$ti u) L si)$*e 2e!ri*e seiEure Bgastritis P< Manage)ent: = = = = = = = 5IFD D# GaD* 0,<C9 "0 gttM5 )i ro Diet F =C CC M 2 hours /ith )inera* )i. 1,1 through G?+ 5n-& De2tria.one C00 )g M 12 hrs M 5I 5n-& Aanitidin 12 )gM 12 hrs M 5I Para eta)o* " . th 5 M G?+ Diet )i*3 100 M" hrs %ia G?+ #$oo*ing /ith GaD* 0,9 9 B

Plan < :F+ +est 'e)te0ber8 16t( 291, :-t( da.; ' < Fe%er(B), ;e)ate)esis(B)

2C

O< #ens: DM, +e)$: "8,9oD, ;A : 102 !$), AA : 28 !$) ;ead, eye : :ight re2*e.es(LML), iso hori $u$i*, nor)a* on-un ti%a $a*$e!ra in2erior& @arM)outh: nor)a*& Gose: G?+ inserted& +hora. : #y))etri a* 2usi2or)& ;A : 102 !$), regu*er, )ur)ur (B)& AA : 28 !$), regu*er& Go ra 3*es, easi*y seen ri!s '!do)en : #oe$e*& Perista*ti /as nor)a*& :i%erMs$*eenMrena*: not $a*$a!*e& @.tre)ities : Pu*se 102 !$), regu*ar, ade,uate $ressure and %o*u)e, /ar) a ra*, DA+ N "1 A< #us$e t ?@A P< Manage)ent: = = = = = = 5IFD D# GaD* 0,<C9 "0 gttM5 )i ro Diet F =C CC M 2 hours /ith )inera* )i. 1,1 through G?+ 5n-& De2tria.one C00 )g M 12 hrs M 5I 5n-& Aanitidin 12 )gM 12 hrs M 5I Para eta)o* " . th 5 M G?+ Diet )i*3 100 M" hrs %ia G?+

Plan < >GO 'e)te0ber8 29t( 291, :/t( da.; ' < Go 2e%er, Go !*eeding, Go seiEure O < #ens: DM, +e)$: "8&8oD, ;A : 100 !$), AA : 2< !$) ;ead, eye : :ight re2*e.es(LML), iso hori $u$i*, nor)a* on-un ti%a $a*$e!ra in2erior, earM)outh: nor)a*, nose: G?+ inserted +hora. : #y))etri a* 2usi2or)& ;A : 100 !$), regu*er, no )ur)ur& AA : 2< !$), regu*er& Go ra 3*es& '!do)en : #oe$e*& Perista*ti /as nor)a*& :i%erMs$*eenMrena* : nor)a* @.tre)ities : Pu*se 100 .Mi, regu*ar, ade,uate $M%, /ar) a ra*, DA+ N "1 A < #i)$*e Fe!ri*e #eiEure L #us$e t ?@A P< *anage0ent

28

= = = = = =

5IFD D# GaD* 0,<C9 "0 gttM5 )i ro Diet F =C CC M 2 hours /ith )inera* )i. 1,1 through G?+ 5n-& De2tria.one C00 )g M 12 hrs M 5I 5n-& Aanitidin 12 )gM 12 hrs M 5I Para eta)o* " . th 5 M G?+ Diet )i*3 100 M" hrs %ia G?+

2=

= =

BNO > Abdo0en Re&ult :Radiolog. con&ultation; < Gor)a* C(e&t ?=Ra. Re&ult :Radiolog. con&ultation; < e)$hyse)a *o a*iEed at the *e2t *ung dan e22use $*eura at the *e2t *ung

28

29

'e)te0ber8 21&t 291, :1t( da.; ' < Go 2e%er, Go !*eeding, Go seiEure O < #ens: DM, +e)$: "8,8oD, ;A : 100 !$), AA : 28 !$) ;ead, @ye : :ight re2*e.es(LML), iso hori $u$i*, on-un ti%a $a*$e!ra in2erior nor)a*, earM)outh: nor)a* nose: G?+ inserted +hora. : #y))etri a* 2usi2or)& ;A : 100 !$), regu*er, no )ur)ur& AA : 28 !$), regu*er& Go ra 3*es & '!do)en : #oe$e*& $erista*ti (L) nor)a*, *i%erMs$*eenMrena*: nor)a* @.tre)ities : Pu*se 100 .Mi, regu*ar, ade,uate $M%, /ar) a ra*, DA+ N "1 A < #us$e t ?@A L e)$ise)a (sin) L e22use $*eura (sin) P< *anage0ent = = = = 5IFD D# GaD* 0,<C9 "0 gttM5 )i ro 5n-& De2tria.one C00 )g M 12 hrs M 5I Para eta)o* " . th 5 M G?+ Diet )i*3 100 M" hrs %ia G?+

"0

Plan < >ariu) )ea* (2"M09M201"), !*ood g*u ose *e%e*, o)$*ete !*ood ount, e*e tro*yte, +", +<, +#; "aborator. Re&ult< #e$te)!er, 21st 201" Co0)lete Blood Count ;e)og*o!in (;?>) @ritrosit (A>D) :eu3osit (4>D) ;e)ato3rit +ro)!osit (P:+) MDI MD; MD;D AD4 MPI PD+ PD4 Di%tel Geutro2i* :i)2osit Monosit @osino2i* >aso2i* Geutro2i* '!so*ut :i)2osit '!so*ut Monosit '!so*ut @osino2i* '!so*ut >aso2i* '!so*ut Mor$ho*ogy : @rythro yte : nor)o ro) nor)o yti 4>D P*ate*et : nor)a* a$$earan e : nor)a* a$$earan e g9 108M ))" 10"M ))" 9 10"M ))" 2: Pg g9 9 2: 9 2: 9 9 9 9 9 10"MP: 10"MP: 10"MP: 10"MP: 10"MP: 10&C0 <&09 11&"2 "<&00 <C" 8"&10 2C&=0 "0&90 1C&80 10&00 0&<C 10&80 ""&"0 <9&20 12&10 C&10 0&"00 "&== C&C= 1&"= 0&C8 0&0" 11&" O 1<&1 <&<0 O <&<8 <&CB 1"&C "= O <1 21= O <9= 81 O 9C 2C O 29 29 O "1 11&8 O 1<&8 =&2 B 10&0

"= O 80 20 O <0 2O8 1O8 0O1 2&< B =&" 1&= B C&1 0&2 B 0&8 0&10 B 0&"0 0 B 0&1

"aborator. Re&ult< #e$te)!er, 21th 201" Clinical C(e0i&tr. Dar!ohydrate Meta!o*is) ?*u3osa Darah (#e/a3tu) @*e tro*yte Gatriu) (Ga)

MgMd: )@,M:

1"8,00 1"=

N200 1"CB1CC

"1

Ka*iu) (K) )@,M: <&8 "&8BC&C K*orida (D*) )@,M: 108 98B108 C(e&t ?=Ra. Re&ult :Radiolog. con&ultation; < @)$hise)a in *e2t *ung, and $*eura e22usion in *e2t *ung BNO > Abdo0en Re&ult :Radiolog. con&ultation; < Gor)a* 'e)te0ber8 22nd 291, :2t( da.; ' < Fe%er(B), ;e)ate)esis(B) O < #ens: DM, +e)$: "8,8oD, ;A : 98 !$), AA : 22 !$) ;ead, @ye : :ight re2*e.es(LML), iso hori $u$i*, on-un ti%a $a*$e!ra in2erior nor)a*, earM)outh: nor)a* nose: G?+ inserted +hora. : #y))etri a* 2usi2or)& ;A : 98 !$), regu*er, no )ur)ur& AA : 22 !$), regu*er& Go ra 3*es & '!do)en : #oe$e*& $erista*ti /as nor)a*, *i%erMs$*eenMrena*: nor)a* @.tre)ities : Pu*se 98 .Mi, regu*ar, ade,uate $M%, /ar) a ra*, DA+ N "1 A < #us$e t ?@A L e)$ise)a (sin) L e22use $*eura (sin) P< *anage0ent = = = = 5IFD D# GaD* 0,<C9 "0 gttM5 )i ro 5n-& De2tria.one C00 )g M 12 hrs M 5I Para eta)o* " . th 5 M G?+ Diet )i*3 100 M" hrs %ia G?+

'e)te0ber8 2,rd 291, :3t( da.; ' < Fe%er(B), ;e)ate)esis(B) O < #ens: DM, +e)$: "8,8 oD, ;A : 98 !$), AA : 28 !$) ;ead, @ye : :ight re2*e.es(LML), iso hori $u$i*, on-un ti%a $a*$e!ra in2erior nor)a*, earM)outh: nor)a* nose: G?+ inserted +hora. : #y))etri a* 2usi2or)& ;A : 98 !$), regu*er, no )ur)ur& AA : 28 !$), regu*er& Go ra 3*es & '!do)en : #oe$e*& $erista*ti (L) nor)a*, *i%erMs$*eenMrena*: nor)a* @.tre)ities : Pu*se 110 .Mi, regu*ar, ade,uate $M%, /ar) a ra*, DA+ N "1 A < #us$e t ?@A L @)2ise)a (sin) L @22usi P*eura (sin) L #i)$*e Fe!ri*e #eiEure

"2

P< *anage0ent = = = = 5IFD D# GaD* 0,<C9 "0 gttM5 )i ro 5n-& De2tria.one C00 )g M 12 hrs M 5I Para eta)o* " . th 1 1M2 M G?+ Diet )i*3 100 M" hrs %ia G?+

Plan < /aiting 2or !ariu) )ea* resu*t 'e)te0ber8 2-t( 291, :6t( da.; ' < Fe%er(B), ;e)ate)esis(B) O < #ens: DM, +e)$: "8 oD, ;A : 98 !$), AA : 28 !$) ;ead, @ye : :ight re2*e.es(LML), iso hori $u$i*, on-un ti%a $a*$e!ra in2erior nor)a*, earM)outh: nor)a* nose: nor)a* +hora. : #y))etri a* 2usi2or)& ;A : 98 !$), regu*er, no )ur)ur& AA : 28 !$), regu*er& Go ra 3*es & '!do)en : #oe$e*& $erista*ti (L) nor)a*, *i%erMs$*eenMrena*: nor)a* @.tre)ities : Pu*se 98 !$), regu*ar, ade,uate $M%, /ar) a ra*, DA+ N "1 A < #us$e t ?@A L @)2ise)a (sin) L @22usi P*eura (sin) L #i)$*e Fe!ri*e #eiEure P< *anage0ent = = = = = = 5IFD D# GaD* 0,<C9 "0 gttM5 )i ro 5n-& De2tria.one C00 )g M 12 hrs M 5I Para eta)o* " . th 1 1M2 M G?+ Diet )i*3 100 M" hrs %ia G?+ ) L Iento*in Ge!u*e GaD: 0,9 9 (2,C Dhest 2isiothera$y

Plan < /aiting 2or the resu*t o2 !ariu) )ea* 'e)te0ber8 2/t( 291, :19t( da.; ' < Fe%er(B), ;e)ate)esis(B) O < #ens: DM, +e)$: "8,8 oD, ;A : 98 !$), AA : 28 !$) ;ead, @ye : :ight re2*e.es(LML), iso hori $u$i*, on-un ti%a $a*$e!ra in2erior nor)a*, earM)outh: nor)a* nose: nor)a*

""

+hora. : #y))etri a* 2usi2or)& ;A : 98 !$), regu*er, no )ur)ur& AA : 28 !$), regu*er& Go ra 3*es & '!do)en : #oe$e*& $erista*ti (L) nor)a*, *i%erMs$*eenMrena*: nor)a* @.tre)ities : Pu*se 98 !$), regu*ar, ade,uate $M%, /ar) a ra*, DA+ N "1 A < #us$e t ?@A L @)2ise)a (sin) L @22uusi P*eura (sin) L #i)$*e Fe!ri*e #eiEure P< *anage0ent = = = = 5IFD D# GaD* 0,<C9 "0 gttM5 )i ro Para eta)o* " . th 1 1M2 Ge!u*e GaD: 0,9 9 (2,C Dhest 2isiothera$y ) L Iento*in

Plan < /aiting 2or the resu*t o2 !ariu) )ea* 'e)te0ber8 21t( 291, :11&t da.; ' < Fe%er(B), ;e)ate)esis(B) O < #ens: DM, +e)$: "= oD, ;A : 9< !$), AA : 28 !$) ;ead, @ye : :ight re2*e.es(LML), iso hori $u$i*, on-un ti%a $a*$e!ra in2erior nor)a*, earM)outh: nor)a* nose: nor)a* +hora. : #y))etri a* 2usi2or)& ;A : 9< !$), regu*er, no )ur)ur& AA : 28 !$), regu*er& Go ra 3*es & '!do)en : #oe$e*& $erista*ti (L) nor)a*, *i%erMs$*eenMrena*: nor)a* @.tre)ities : Pu*se 9< !$), regu*ar, ade,uate $M%, /ar) a ra*, DA+ N "1 A < ?@A L @)2ise)a (sin) L @22usi P*eura (sin) L si)$*e 2e!ri*e seiEure P< *anage0ent = = = = = = 5IFD D# GaD* 0,<C9 "0 gttM5 )i ro Para eta)o* " . th 1 1M2 O)e$raEo*e ta!s " . 8 )g Diet M55 1100 33a* L 2< gr o2 Protein Ge!u*e GaD: 0,9 9 (2,C Dhest 2isiothera$y ) L Iento*in

"<

Plan < D+B# an thora3s /ithout ontrass

"C

"8

'e)te0ber8 22t( 291, :12nd da.; ' < Fe%er(B), ;e)ate)esis(B) O < #ens: DM, +e)$: "= oD, ;A : 98 !$), AA : 28 !$) ;ead, @ye : :ight re2*e.es(LML), iso hori $u$i*, on-un ti%a $a*$e!ra in2erior nor)a*, earM)outh: nor)a* nose: nor)a* +hora. : #y))etri a* 2usi2or)& ;A : 98 !$), regu*er, no )ur)ur& AA : 28 !$), regu*er& Go ra 3*es & '!do)en : #oe$e*& $erista*ti (L) nor)a*, *i%erMs$*eenMrena*: nor)a* @.tre)ities : Pu*se 98 !$), regu*ar, ade,uate $M%, /ar) a ra*, DA+ N "1 A < ?@A L @)2ise)a (sin) L @22usi P*eura (sin) L ;iata* ;ernia L #i)$*e Fe!ri*e #eiEure P< *anage0ent = = 5IFD D# GaD* 0,<C9 "0 gttM5 )i ro Para eta)o* " . th 1 1M2

"=

= = = = Plan <

O)e$raEo*e ta!s " . 8 )g Diet M55 1100 33a* L 2< gr o2 Protein Ge!u*e GaD: 0,9 9 (2,C Dhest 2isiothera$y Donsu*t to Pediatri #urgery De$art)ent, D+B# an thora3s /ithout ) L Iento*in

ontrass 'e)te0ber8 23t( 291, :1,rd da.; ' < Fe%er(B), ;e)ate)esis(B) O < #ens: DM, +e)$: "= oD, ;A : 98 !$), AA : 2< !$) ;ead, @ye : :ight re2*e.es(LML), iso hori $u$i*, on-un ti%a $a*$e!ra in2erior nor)a*, earM)outh: nor)a* nose: nor)a* +hora. : #y))etri a* 2usi2or)& ;A : 98 !$), regu*er, no )ur)ur& AA : 2< !$), regu*er& Go ra 3*es & '!do)en : #oe$e*& $erista*ti (L) nor)a*, *i%erMs$*eenMrena*: nor)a* @.tre)ities : Pu*se 98 !$), regu*ar, ade,uate $M%, /ar) a ra*, DA+ N "1 A < ?@A L @)2ise)a (sin) L @22uusi P*eura (sin) L ;iata* ;ernia L #i)$*e Fe!ri*e #eiEure P< *anage0ent = = = = = = 5IFD D# GaD* 0,<C9 "0 gttM5 )i ro Para eta)o* " . th 1 1M2 O)e$raEo*e ta!s " . 8 )g Diet M55 1100 33a* L 2< gr o2 Protein Ge!u*e GaD: 0,9 9 (2,C Dhest 2isiothera$y ) L Iento*in

Plan < Donsu*t to Pediatri #urgery De$art)ent, , D+B# an thora3s /ithout ontrass

"8

CHAPTER I# DI'CU''ION AND 'U**AR@ YG, 2e)a*e, " year 9 )onths, a)e to A#;'M Medan on #e$te)!er, 1Cth, 201" /ith )ain o)$*aint he)ate)esis& On $hysi a* e.a)ination the $atient *oo3s nor)a* a$$eran e /ith an o$erationa* s ar $ost hernia surgery& :a!oratory 2inding sho/s ane)ia and in reases o2 )onosit and *i)2osit& Patient a*so o)$*aints neuro*ogy )ani2estation su h as seiEure (on the 2irst days o2 hos$ita*iEation), $hysi a* e.a)ination sho/s a!nor)a* )o%e)ent at /ho*e !ody& 5n the other hand hest QBray /as $er2or)ed in the third day and the resu*t /as : e)$hise)a in *e2t *ung, and $*eura e22usion in *e2t *ung& >ut on $hysi a* e.a)ination not sho/n a!nor)a*ity su h as no dys$noe, ra 3*es, or retra tion /as not 2ound unti* the re ent 2o**o/ u$& D*ini a**y, the $atient sho/s i)$ro%e)ent in the third day that seen 2ro) G?+ /hi h !*eeding /as not 2ound& & 5n this ase the ause o2 ?5 !*eeding /as $ost hernia surgery& #he /as diagnosed /ith si)$*e 2e!ri*e seiEure L ?5 !*eeding, !ut sti** not get e%iden e o2 the auses, so needs 2urther in%estigations& >y !ariu) ene)a ,YG is diagnosed /ith hiata* hernia and is )anaged 2or /hi*e /ith O)e$raEo*e ta!s " . 8 )g 8 diet M55 1100 33a* L 2< gr o2 Protein 8 ne!u*e GaD: 0,9 9 (2,C )L Iento*in and Dhest 2isiothera$y& Fro) our dis ussion, /e $resu)ed that the ?5 !*eeding /ere aused !y the reason that she had $ost hernia surgery& On the other hand, she is a*so ha%e he)ato*ogi and res$iratory )ani2estation su h as ane)ia and e22use $*eura, it aused !y the o)$*i ation o2 the hiata* hernia&

"9

RE5ERENCE' 1& John D, +i)othy +, Gostrant& Textbook of Gastroenterology 5th edition. 4i*ey >*a 3/e**& 2009& 2& Fau i, >raun/a*d, Kas$er et a*& Harrisons Internal Medicine 17th edition& +he M ?ra/B;i** Do)$anies, 5n & 2008 & the (nited #tates o2 ')eri a& "& Po*o)s3y M, Peters J;, # h/artE #5& ;iata* hernia and disorders o2 the s$ine: a histori a* $ers$e ti%e& Dis sophag!s& O t 2C 2011 <& >ur3itt DP, Ja)es P'& "o#$resid!e diets and hiat!s hernia& :an et& Ju*21 19=" : 28B"0 C& #a*%ador A, Du!e E ', Po*o)s3y M, ?e**erson O, Jones D@, Aay)ond DP, et a*. % ne# era in esophageal diagnostics : reso*ution )ano)erty& J ') Do** #urg& Jun 2009 : 10"CB10<< 8& ///&)dguide*ines& o)MherniaBhiata*Mdi22erentia*Bdiagnosis =& Kahri*as PJ& ?@AD $athogenesis, $atho$hysio*ogy and *ini a* )ani2estations& &le'e &lin ( Med& 200"6=0(#u$$* C):#<O19& 8& ;uang #Y, :e%ine M#, Au!esin #@, et a*& :arge hiata* hernia /ith 2*o$$y 2undus: *ini a* and radiogra$hi 2indings& ') J Aadio* 200=6188:980&