Stomach and Hernias GASTRITIS Hiatal Hernia NEOPLASMS Incisional Hernia PEPTIC ULCER DISEASE Inguinal Hernia Umbilical Hernia PYLORIC STENOSIS Ventral Hernia Gastritis Definition: inflammation of the stomach lining Causes: NSAID use, ASA, Helicobactyer pylori infection, stress, EtOH Clinical Features: Anorexia, Epigastric pain, N/V, Hematemesis, erosive gastritis is often asymptomatic Diagnosis: Endoscopy with biopsy. Gastritis is not a clinical diagnosis! Treatment H2 Blockers BID, PPI OD or BID, Discontinue ASA and NSAIDS Fluids and blood transfusions may be indicated Neoplasms Affects men twice as often as women Often diagnosed late stage with poor prognosis Causes: tobacco/smoking, diet high in processed food and nitrates contributes to risk Clinical Features: dyspepsia, epigastric pain, early satiety, weight loss, anorexia, vomiting Often asymptomatic until late stage Diagnosis: endoscopy with brushings/biopsy Treatment: Surgery with radiation. Peptic Ulcer Disease Definition: break in gastic/duodenal mucosa is overwhelmed by acid and pepsin. Definition: break in gastic/duodenal mucosa is overwhelmed by acid and pepsin. Clinical Features: Epigastric pain that can radiate to the back or LUQ. Pain often presents at night and may be exacerbated or relieved with food. N/V, hematemesis and melena are also common. Ulcers caused by NSAIDS may be painless. Abrupt increase in pain suggest perforation Diagnosis: endoscopy with antral biopsy for H. pylori is the gold standard Treatment: H2 blockers and PPI BID with dietary changes. If severe ulcer or actively bleeding, they may require hospitalization, NPO, NG suction and endoscopic sclerotherapy. Pyloric Stenosis Definition: hypertrophy of pyloric muscle causing obstruction Occurs in roughly 1 out of 500 births This is acquired not congenital Clinical presentation: hungry infants that are feeding well and has non bilious projectile vomit with each feed, poor weight gain or weight loss, constipation Physical exam shows a distended upper abdomen after feeds, peristaltic wave from left to right, “olive” palpable in RUQ Diagnosis: UGI shows delayed gastric emptying with elongated narrow pyloric channel “string sign” and labs will show hypokalemia, hypochloremia Treatment: correct electrolytes first, surgical pyloromyotomy Hernias Definition: The exit of an organ through the cavity wall. Sub-classifications: Reducible: Contents of the hernia may be reduced completely into peritoneal cavity. Irreducible: Contents may not be reduced into the peritoneal cavity. The inability to reduce often occurs secondary to adhesion between the contents and the inner wall of the containing sac. Obstructed: Irreducible hernia in which the blood supply is not yet compromised. Always has bowel in the sac. Strangulated: Obstructed hernia in which the blood supply is compromised. Can result in gangrene and perforation of the affected segment of bowel. May also have omentum or other viscera in the sac. Hiatal Hernia Definition: enlarged esophageal hiatus or the diaphragm with intra-abdominal contents protruding into the hernia Clinical Features: heartburn, regurgitation, dysphagia, chest pain, sour taste, hoarseness, cough Diagnosis: CXR will show retro-cardiac air bubble in the intrathoracic portion of the stomach Upper GI series with contrast is gold standard and will demonstrate a qualitative assessment of esophageal motility Treatment: Lifestyle modifications including weight loss, avoiding large meals, avoid lying down after meals, elevate the head of the bed. Avoid: EtoH, acidic food, nicotine, chocolate, caffeine, fatty foods Meds: PPI OD or BID, H2 blocker Surgical repair is used in large defects (>5cm) Incisional Hernia Iatrogenic hernia after abdominal surgery secondary to breakdown of facial closure 2-10% occurrence rate 20-40% recurrence rate after surgical repair of the hernia Clinical features: patients present with a bulge at the surgical incision site. Bulge may become larger upon standing or increasing intra abdominal pressure. Treatment: Surgery is done if the hernia is incarcerated, growing, or causing pain. Inguinal Hernia Indirect Inguinal Hernia Definition: Congenital hernia in which the parietal peritoneum passes through the internal inguinal ring and canal due to a patent processus vaginalis. It is located lateral to the inferior epigastric artery and above and medial to the pubic tubercle. Direct Inguinal Hernia Definition: Acquired hernia in which the parietal peritoneum passes directly though the abdominal wall (Hesselbach triangle) medial to the inferior epigastric artery and above the pubic tubercle. Clinical Features: Bulge in the groin that disappears when lying flat.is it is obstructed or strangulated there can be associated pain and N/V Physical exam: Most can be observed as a bulge in the groin with the patient standing. Can also be found if the patient coughs while placing the index finger at the external ring. Direct hernia will push again the finger pulp and indirect hernia will push against the finger tip. Diagnosis: Usually made on clinical exam or ultrasound Treatment: Surgical repair. Umbilical Hernia Definition: A defect in the anterior abdominal wall fascia allowing protrusion of a peritoneal sac and may contain intra abdominal contents. Some may resolve spontaneously Most commonly found in a healthy infant. Occurs in upto 75% of infant weighing under 3.3 pound or 1500 grams Diagnosis: Found on exam with a bulge at the umbilicus Treatment: If less than 1cm, observation only until age 4-5 If greater than 1.5-2cm, unlikely to close spontaneously and repair is otfen done around age 2-3 if incarcerated or strangulated, surgical repair is urgent..