Hiatal Hernia - A neglected disease with important clinical significance 성균관대학교의과대학내과이준행
도무지어디가어딘지알수없을때? 내시경기계고장 ( 공기가안들어가는경우 ) Hiatal hernia Situs inversus Gastric volvulus Diaphragmatic evantration 소만의단축 ( 위축성변화 ) 위암 ( 보만 4형진행성위암 )
Biopsy: TUBULAR ADENOCARCINOMA, P/D with multiple endolymphatic tumor emboli
Searching for lost body in a patient with gastric cancer - 왜위의모양이이렇게도이상한것일까? 커다란 fundus 아래에 antrum 만있는것같은느낌이었음. Body 는어디로사라졌는가?
소만의단축 소만의단축개념도. 민영일저. 상부위장관내시경진단 (1993)
Diaphragmatic eventration
Diaphragmatic eventration
Types of gastric volvulus
Gastric volvulus
Situs inversus Retroflection 에서위치잡기가어려움 fundus antrum 찌글어진십이지장구부
Hiatal hernia: 크거나작거나 성균관대학교의과대학내과이준행
커도문제작아도문제 Large hiatal hernia 초심자는길을잃을수있다. 다양한합병증이가능하다. 수술이필요하다. Small hiatal hernia 진단기준이애매하다. 임상적의미가있는지판단이어렵다
Two types of hiatal hernia http://www.njsurgery.com/
Three types of hiatal hernia
Four types of hiatal hernia
큰것먼저 성균관대학교의과대학내과이준행
Chronic IDA (68/F)
Hiatal hernia and bleeding
Hiatal hernia with recurrent ulcer - 2012 년 melena, 이후만성빈혈, 2015 년 10 월 hematemesis
Types of hernia
Schematic Understanding of Endoscopic findings of EGJ 성균관대학교의과대학내과이준행
Normal esophagogastric junction Diaphragm Phrenoesophageal ligament Ascending limb Descending limb Infradiaphragmatic fascia Squamocolumnar junction
Endoscopic anatomy of EGJ Esophagus 3 cm PZ Esophagogastric junction (EGJ) = Proximal margin of gastric folds = Distal end of palisade zone = Pinchcock action (PCA) = Squamocolumnar junction Stomach
Sequential changes by inflation (1)
Sequential changes by inflation (2) Mueller maneuver: inspiration against a closed glottis
Anatomy of sliding hiatal hernia A-ring = muscular ring Ampulla Hernia sac B-ring = mucosal ring = Schatzki ring
Anatomy of sliding histal hernia
Sliding type hiatal hernia Hernia sac Squamocolumnar junction = B-ring Diaphragmatic orfice Diaphragmatic orfice Ampulla A-ring B-ring
Curved EG junction EG junction을구성하는요소중횡경막은상당히중요하다. Pinchcork action은주로횡경막 right crus 에의해서이루어진다. 정상인에서도식도와위사이에약간의 curve가있다. 보통 hiatal hernia가있을때식도에서위로진입하기위하여약간의 turn이필요하다. 정상적인경우에존재하는 curve가강조되어나타나기때문이다.
Size (length) of hiatal hernia - The 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 Modified from the lecture slides of Y. Romero (2010). Esophagus Interest Group 2003
Esophagus is curved
Short esophgus Hiatal hernia가있는환자에서식도길이가짧은경우가많다. 식도길이가짧아서 hiatal hernia가발생한것인지아니면 hiatal hernia로인하여식도길이가짧아진것인지명확하지않다. (van Herwaarden. Eur J Gastroenterol Hepatol 2005;16:831-835) 인과관계와무관하게 short esohagus와 hiatal hernia가있는경우 EG junction의 curve는없어진다.
다음으로중간것 성균관대학교의과대학내과이준행
Paraesophageal hernia gastric folds diaphragmatic opening hernia sac ulcer scar
Paraesophageal hernia with bleeding - MERS 때문에추적내시경이몇달늦어짐
목요점심집담회증례. 진단은? ( 사진한장 )
PPI 투여한달후호전된모습
2 년전에도비슷한모양이었습니다.
Two Famous Names - Schatzki and Cameron 성균관대학교의과대학내과이준행
Schatzki (1901-1992) - a German radiologist
Schatzki ring http://www.mindspring.com/~dmmmd2/es_ge_04.html
Hiatal hernia & stricture
Hiatal hernia & stricture - Schatzki ring
Hiatal hernia with stenosis - Schatzki ring
Cameron ulcers Gastroenterology 2005;129:7
IDA 로발현한 Cameron ulcer 한성희 ( 한양대 ). 대한소화기내시경학회지 2006;32:33-36
Cameron ulcer
마지막으로작은것 성균관대학교의과대학내과이준행
Evaluation of EG junction is tricky. 들어갈때 나올때 오늘의증례 20080617
Evaluation of EG junction is tricky.
Is there a hiatal hernia or not?
Hiatal hernia and reflux esophagitis
Hiatal hernia and reflux esophagitis
Barrett s esophagus
결론 : 이제는알수있다! 내시경기계고장 ( 공기가안들어가는경우 ) Hiatal hernia Situs inversus Gastric volvulus Diaphragmatic evantration 소만의단축 ( 위축성변화 ) 위암 ( 보만 4형진행성위암 )
경청해주셔서감사합니다.