Mide Fıtığı ve Tedavisi
Özet
Mide fıtığı (hiatal herni), diyaframdaki boşluğun genişlemesi sonucu midenin göğüs boşluğuna doğru kayması durumudur. En yaygın türü gastroözofageal birleşim yerinin yukarı kaymasıyla karakterize edilen Tip I (sliding) hernidir; Tip II, III ve IV ise paraözofageal fıtıklar olarak sınıflandırılır ve mide dışında organların da fıtıklaşabildiği daha nadir, mekanik komplikasyonlara yol açabilen türlerdir. Küçük fıtıklar genellikle asemptomatik seyrederken, büyük fıtıklarda mide yanması, regürjitasyon ve disfaji gibi gastroözofageal reflü hastalığı (GÖRH) semptomları ve komplikasyonları görülür. Tanıda baryumlu grafi, üst gastrointestinal sistem endoskopisi ve yüksek çözünürlüklü manometri kullanılır. Semptomatik sliding fıtıkların tedavisinde öncelikle yaşam tarzı değişiklikleri, antasitler, H2 reseptör antagonistleri ve proton pompa inhibitörleri (PPİ) gibi medikal yöntemlerle reflü yönetimi hedeflenir. İlaç tedavisine yanıt vermeyen, şiddetli GÖRH komplikasyonları bulunan veya kronik öksürük gibi gastrointestinal dışı semptomları olan dirençli vakalarda ise cerrahi müdahale gerekir. Cerrahi seçenekler arasında altın standart olarak kabul edilen laparoskopik Nissen fundoplikasyonunun yanı sıra kısmi fundoplikasyonlar, Hill gastropeksi, manyetik sfinkter büyütme (LINX) ve Stretta gibi endoskopik yöntemler yer almaktadır.
A hiatal hernia occurs when the opening in the diaphragm enlarges, allowing the stomach to displace upward into the chest cavity due to intra-abdominal pressure. The condition is primarily categorized into Type I (sliding) hernia, characterized by the upward migration of the gastroesophageal junction, and Types II, III, and IV (paraesophageal) hernias, which involve a true hernia sac and can lead to severe mechanical complications, including the herniation of other abdominal organs. While small sliding hernias are frequently asymptomatic, larger ones present with prominent symptoms of gastroesophageal reflux disease (GERD), such as heartburn, regurgitation, and dysphagia. Diagnostic modalities include barium swallow radiograph, upper endoscopy, and high-resolution manometry. The management of symptomatic sliding hernias focuses on controlling GERD through lifestyle modifications and medical therapies, including antacids, H2 receptor antagonists, and proton pump inhibitors (PPIs). Surgical intervention is indicated for patients with intractable symptoms, medical non-compliance, severe erosive esophagitis, or extraintestinal manifestations like chronic cough. Laparoscopic Nissen fundoplication remains the gold standard surgical procedure, complemented by alternative approaches such as partial fundoplications, Hill gastropexy, magnetic sphincter augmentation (LINX), and endoscopic techniques like Stretta.
Referanslar
Rosen M, Blatnik J, Louie BE. Surgical management of paraesophageal hernia. UpToDate com. 2019.
Miller J. Bacterial infections of the lungs and bronchial compressive disorders. General thoracic surgery. 2005:1219-1224.
Weston AP. Hiatal hernia with Cameron ulcers and erosions. Gastrointestinal endoscopy clinics of North America. 1996;6(4):671-679.
DANTEÆ E, POP CS, FILDAN AP, et al. PARAOESOPHAGEAL HERNIA REVEALED BY SMALL PLEURAL EFFUSION. Archives of the Balkan Medical Union vol. 2016;51(1):138-141.
Kahrilas PJ. Hiatus hernia causes reflux: fact or fiction? Gullet. 1993;3(1 SUPPL.):21-30.
Hill LD, Kozarek RA, Kraemer SJ, et al. The gastroesophageal flap valve: in vitro and in vivo observations. Gastrointestinal endoscopy. 1996;44(5):541-547.
Wright RA, Hurwitz AL. Relationship of hiatal hernia to endoscopically proved reflux esophagitis. Digestive diseases and sciences. 1979;24(4):311-313.
Ott DJ, Gelfand DW, Chen YM, et al. Predictive relationship of hiatal hernia to reflux esophagitis. Gastrointestinal radiology. 1985;10(1):317-320.
Bredenoord AJ, Weusten BL, Timmer R, et al. Intermittent spatial separation of diaphragm and lower esophageal sphincter favors acidic and weakly acidic reflux. Gastroenterology. 2006;130(2):334-340.
Kahrilas PJ, Kim HC, Pandolfino JE. Approaches to the diagnosis and grading of hiatal hernia. Best practice & research Clinical gastroenterology. 2008;22(4):601-616.
Sontag S. The medical management of reflux esophagitis. Role of antacids and acid inhibition. Gastroenterology Clinics of North America. 1990;19(3):683-712.
Simon B, Ravelli G, Goffin H. Sucralfate gel versus placebo in patients with non‐erosive gastro‐oesophageal reflux disease. Alimentary pharmacology & therapeutics. 1996;10(3):441-446.
Komazawa Y, Adachi K, Mihara T, et al. Tolerance to famotidine and ranitidine treatment after 14 days of administration in healthy subjects without Helicobacter pylori infection. Journal of gastroenterology and hepatology. 2003;18(6):678-682.
Tsai H, Chapman R, Shepherd A, et al. Esomeprazole 20 mg on‐demand is more acceptable to patients than continuous lansoprazole 15 mg in the long‐term maintenance of endoscopy‐negative gastro‐oesophageal reflux patients: the COMMAND Study. Alimentary pharmacology & therapeutics. 2004;20(6):657-665.
Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Official journal of the American College of Gastroenterology| ACG. 2013;108(3):308-328.
FINDIK ÜY, ÜNVER ÖÜS, EYİ ÖÜS. Gastrointestinal Sistemin Cerrahi Hastalıkları ve Hemşirelik Bakımı: Nobel Tıp Kitabevi; 2019.
Corey KE, Schmitz SM, Shaheen NJ. Does a surgical antireflux procedure decrease the incidence of esophageal adenocarcinoma in Barrett's esophagus? A meta-analysis. The American journal of gastroenterology. 2003;98(11):2390-2394.
Triadafilopoulos G, DiBaise JK, Nostrant TT, et al. The Stretta procedure for the treatment of GERD: 6 and 12 month follow-up of the US open label trial. Gastrointestinal endoscopy. 2002;55(2):149-156.
Park A, Weltz AS, Sanford Z, et al. Laparoscopic antireflux surgery (LARS) is highly effective in the treatment of select patients with chronic cough. Surgery. 2019;166(1):34-40.
Triadafilopoulos G, DiBaise JK, Nostrant TT, et al. Radiofrequency energy delivery to the gastroesophageal junction for the treatment of GERD. Gastrointestinal endoscopy. 2001;53(4):407-415.
Bremner C, Lynch V, Ellis Jr F. Barrett's esophagus: congenital or acquired? An experimental study of esophageal mucosal regeneration in the dog. Surgery. 1970;68(1):209-216.
Patti MG, Goldberg HI, Arcerito M, et al. Hiatal hernia size affects lower esophageal sphincter function, esophageal acid exposure, and the degree of mucosal injury. The American journal of surgery. 1996;171(1):182-186.
Campos GM, Peters JH, DeMeester TR, et al. Multivariate analysis of factors predicting outcome after laparoscopic Nissen fundoplication. Journal of Gastrointestinal Surgery. 1999;3(3):292-300.
DeMeester TR, Bonavina L, Albertucci M. Nissen fundoplication for gastroesophageal reflux disease. Evaluation of primary repair in 100 consecutive patients. Annals of surgery. 1986;204(1):9.
Ludemann R, Watson D, Jamieson G, et al. Five-year follow-up of a randomized clinical trial of laparoscopic total versus anterior 180 fundoplication. Journal of British Surgery. 2005;92(2):240-243.
