Hiatal hernia and Barrett's esophagus 내과전공의 3 년차김지유
Hiatal hernia
Definition of Hiatal hernia 횡격막의식도열공을통해흉강내로위의일부가탈장되는것. Incidence - 10-20% GERD 환자에서 50-94%
Development of hiatal hernia & phrenoesophageal ligament van Herwaarden. Eur J Gastroenterol Hepatol 2005;16:831-835
Sequential change by air inflation (1)
Sequential change by air inflation (2) Mueller maneuver: inspiration against a closed glottis
Type of Hiatal hernia 1) Type 1 : 활주열공탈장 (sliding hiatal hernia) - 식도열공주위에서식도를횡격막에부착시켜주는횡격막식도인대 (phrenoesophageal ligament) 가헐거워져서하부식도와위식도접합부, 위의상부일부가흉강내로미끄러져들어가는형태의탈장. - 전체식도열공탈장의 95% 를차지. - 역류성식도염을일으키는주요원인의하나. - 대부분후천성, 보통 40 대이후에발생. - 악화인자 : 비만, 무거운것을드는운동, 임신, 위식도역류나식도점막의산화에의해유발되는식도의종주근육의긴장성수축.
Anatomy of hiatal hernia
Hernia sac Squamocolumnar junction = B-ring Diaphragmatic orfice Diaphragmatic orfice Ampulla A-ring B-ring
Lower esophagus is curved cm 34 35 36 37 33 34 35 36 37 38 39 40 41 42 - Diaphragmatic pinch: 38 cm - End of the esophagus: 35 cm - Length of hiatal hernia: 3 cm How the values related to one another is more important than the exact measurement. See the curve at the distal esophagus
Schatzki ring
Hiatal hernia with stenosis due to schatzki ring
Flap valve and Hill grade Hill. Gastrointest Endosc 1996;44:541-547
Type of Hiatal hernia 2) Type 2 : 식도주위탈장 (para-esophageal hernia) - 횡격막식도인대의손상은없고, 열공자체가늘어나서그틈으로위의일부 ( 특히위분문부 ) 가흉강으로빠져들어가는형식의탈장. - GEJ 이 diaphragmatic orfice와같은 level, 즉정상높이에위치 - 매우드문형태.
Type of Hiatal hernia 3) Type 3 : Type 1 + type 2 - 횡격막식도인대의손상으로위식도접합부가밀려올라가면서열공자체가커지고이를통하여위분문부가흉강안으로빠져들어간형태
Hiatal hernia
Mixed type hiatal hernia with bleeding
Short segment hiatal hernia(sshh)
Hiatal hernia and reflux esophagitis
Barrett's esophagus
Definition of Barrett esopahgus Squamocolumnar junction displaced proximal to EG junction Intestinal metaplasia positive Goblet cells
바렛식도의가장중요한내시경소견은 EGJ 보다상방으로이동한 SCJ 이다.
SCJ: 조직학적구분내시경시색깔로구분 ** 정상 SCJ 은분홍빛을띈회색의편평상피와연어빛붉은오렌지색인원주상피간의색조차이로관찰된다
Endoscopic anatomy of EGJ Esophagogastric junction (EGJ) = Proximal margin of gastric folds = Distal end of palisade zone Squamocolumnar junction
BE based on palisading zone
Tongue-like projection in BE
Length of Barrett esophagus M: maximum length C: circumference length 표기예 : C3M5
How would you describe?
Surveillance biopsy 서양은우리보다 Barrett esophagus 가흔함 Barrett esophagus가보이면조직검사를시행. 서양에서의 surveillance 간격은길지만 surveillance 때에는대부분조직검사를함. But, 아직까지서양조차 barrett esophagus surveillance 가환자의 outcome 을좋게했다는연구결과는없음
Surveillance biopsy 우리나라는서양보다바렛식도가드물고대부분단분절. Dysplasia를동반한경우는거의없음. 우리나라에서바렛식도환자의 surveillance 내시경간격은바렛식도의중증도에의하여결정되지않고통상의위암검진간격으로진행되고있음.(1-2년에한번 )
2015 년호주가이드라인 Barrett's esophagus (BE), a common condition, is the only known precursor to esophageal adenocarcinoma (EAC). There is uncertainty about the best way to manage BE, since most people with BE never develop EAC and most patients diagnosed with EAC have no preceding diagnosis of BE.
2015 년호주가이드라인 For the Australian guidelines however, the presence of intestinal metaplasia with morphologically typical goblet cells was considered necessary for the diagnosis of BE. Biopsies from the tubular esophagus containing columnar mucosa without intestinal metaplasia should be given a descriptive diagnosis (e.g. columnar mucosa without intestinal metaplasia), but it is currently recommended that these are not diagnosed as BE until the biological significance of this entity is clarified.
2015 년호주가이드라인 Random four-quadrant biopsies at 2cm intervals are the mainstay for tissue sampling. (Recommendation grade B) Symptomatic patients with BE should be treated with Proton Pump Inhibitor therapy (PPI), with the dose titrated to control symptoms. (Grade C) There is insufficient evidence to recommend the use of acid suppressive therapy for the regression of BE (Grade B).
The effect of PPIs on Barrett s esophagus
2015 년호주가이드라인 Long term outcome studies do not yet support ablation in patients without dysplasia. (Grade B) Ablation of BE should remain limited to individuals with HGD in BE who are at imminent risk of developing esophageal adenocarcinoma. (Grade B) Patients with Barrett's Esophagus length equal to or greater than 3cm may have intensive surveillance, possibly every two to three years following the Seattle protocol. (Grade D)
2016 ACG 가이드라인 Endoscopic biopsy should not be performed in the presence of a normal Z line or a Z line with < 1 cm of variability (strong recommendation, low level of evidence). patients with nondysplastic BE should undergo endoscopic surveillance no more frequently than every 3-5 years. Patients with BE should receive once-daily PPI therapy.