Symptoms and Indications for Surgery
Symptoms of PEH may differ from those of a sliding hernia and are generally an indication for repair. In a study of 147 patients by Allen and colleagues, the most common symptoms were postprandial pain (59%), vomiting (31%), and dysphagia (30%). Cameron ulcers occur in the gastric mucosa as a result of trauma when the stomach slides into the thorax. Other symptoms associated with GER are heartburn, regurgitation, aspiration, and chronic cough. The most feared presentation of PEH is acute incarceration and strangulation due to organoaxial or mesoaxial rotation of the stomach, resulting in ischemia, bleeding, obstruction, or perforation.
Skinner and Belsey and Hill described the high morbidity and mortality associated with these complications. Skinner and Belsey studied 21 patients who were managed expectantly, 6 of whom died. In the second study, Hill found a 30.4% incidence of incarceration in patients who were also managed expectantly. These 2 studies were the basis for aggressive surgical treatment, even in the absence of symptoms.
However, recent studies show different data. Allen followed 21 patients undergoing expectant management for a median of 78 months -- none developed strangulation, and only 2 had worse symptoms.
Stylopolous and colleagues reported that the risk for a life-threatening complication is 1.1% for a patient older than 65 years of age, the overall lifetime risk for death is only 1%, and the probability of developing symptoms requiring emergency surgery is 1.16%. These findings suggest that "watchful waiting" is more appropriate than prophylactic surgery, which has a mortality rate of 5.4% in acutely operated patients.
On the basis of these recent data, most elderly patients (older than 70 years) with few if any symptoms and multiple comorbid conditions can be treated expectantly without surgery. However, young, healthy patients should probably have surgical treatment regardless of presenting symptoms.
Question 2. After making the diagnosis, which of the following tests should be performed?
A. Upper endoscopy
B. 24-hour pH monitoring test
C. Esophageal manometry
D. CT of the chest and abdomen
View the correct Answer.
Answer: A. Upper endoscopy
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