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  4. the causes of hiatal hernia in the elderly, what are the causes of hiatal hernia in the elderly

the causes of hiatal hernia in the elderly, what are the causes of hiatal hernia in the elderly

the causes of hiatal hernia in the elderly, what are the causes of hiatal hernia in the elderly

Etiology of hiatal hernia in the elderly

1. Causes of disease

The lower part of the esophagus is surrounded by the diaphragmatic esophageal membrane. The diaphragmatic esophageal membrane is an elastic fiber membrane that connects the lower esophagus and the diaphragmatic esophageal hiatus. In addition, the lower segment of the esophagus and the esophagogastric junction are fixed to the esophageal hiatus by the upper and lower diaphragmatic esophageal ligaments and the gastric diaphragmatic ligament respectively to maintain their normal position and prevent the esophagogastric junction and other abdominal organs from herniating into the chest cavity. The existence of the above-mentioned normal anatomical structure is the basic condition to ensure the relatively fixed combination of the esophagogastric junction and the diaphragmatic hiatus. There are two causes of hiatal hernia, and these two reasons must be possessed before a hiatal hernia can form.

1. Relaxation and widening of esophageal hiatus

The diameter of the normal diaphragmatic hiatus is 2.5cm. With age, the tissues around the hiatus and the diaphragmatic esophageal membrane elastically atrophy, which widens the esophageal hiatus, relaxes the diaphragmatic esophageal membrane and peri-esophageal ligaments, and gradually loses its fixation of the lower esophagus and the cardia. The role of the normal position. Once the hiatus widens and the diaphragmatic esophageal ligament becomes longer and the esophagus can move up and down, the hiatus becomes a weak link, similar to its hernia formation, which is prone to hernia.

2. Increased intra-abdominal pressure

Increased abdominal pressure and imbalanced pressure in the chest and abdomen are another pathogenic factor, such as obesity, chronic cough, chronic constipation, ascites, late pregnancy, tight belts, frequent hiccups, huge intra-abdominal tumors, etc., can all cause increased abdominal pressure. As a result, tissues such as the abdominal segment of the esophagus, the fundus of the stomach, and the omentum of the intestine are pushed to the wide and loose diaphragmatic hiatus, and herniated into the chest cavity.

The causes of this disease are mainly congenital and acquired, and the latter are more common. In congenital patients, due to hypoplasia, the diaphragmatic esophageal hiatus is wider and looser than normal. Acquired patients are related to diaphragmatic esophageal membrane, peri-esophageal ligament relaxation, hiatus widening, and increased intra-abdominal pressure. As the elderly grow older, the elastic tissue of the diaphragmatic esophageal membrane shrinks, and the surrounding ligaments tend to relax; and among the causes of increased intra-abdominal pressure, such as obesity, chronic constipation, and chronic cough are more common in the elderly, and the elderly have With the above two basic conditions, it is more likely to suffer from hiatal hernia. In addition, esophagitis, esophageal ulcers cause esophageal scar contraction; tumor infiltration caused esophageal shortening; thoracic kyphosis; strong vagus nerve stimulation caused by contraction of the longitudinal muscle of the esophagus and shortening of the esophagus, etc., can all cause the upper esophagus in the chest cavity. Traction causes this disease. Severe chest and abdomen injuries and changes in the normal position of the esophagus, stomach, and diaphragmatic hiatus caused by surgery, or the relaxation of the esophageal membrane and diaphragmatic hiatus caused by surgical traction, can also cause this disease.

2. Pathogenesis

Hiatal hernia can be divided into 3 types according to morphological classification.

1. Sliding hiatal hernia

It is caused by the loosening and widening of the diaphragmatic esophageal hiatus, the loosening of the diaphragmatic esophageal membrane and the peri-esophageal ligaments, so that the subphrenic esophagus and the cardia slide into and out of the thoracic cavity through the loose diaphragmatic esophageal hiatus, so that the normal acute esophagus-gastric junction (His angle) becomes The obtuse angle leads to the destruction of the normal anti-reflux mechanism of the lower esophagus, so this type is often complicated with different degrees of gastroesophageal reflux. This type is the most common clinically, accounting for 85% to 90%. Generally, the hiatus is small. The hernia appears when lying on the back and disappears when standing.

2. Paraesophageal hiatal hernia

Due to the thinning defect of the diaphragmatic esophageal hiatus at the left front edge, the diaphragmatic esophageal hiatus is wide, part of the stomach body (large curvature) and stomach fundus herniated into the thoracic cavity from the left front of the esophagus; while the diaphragmatic esophageal membrane has not been destroyed, the gastroesophageal junction is still under the diaphragm , So that the subdiaphragmatic esophagus segment and the esophagus-gastric junction still maintain the normal anatomical position and the normal physiological sphincter function, the anti-reflux mechanism is not destroyed, so this type of gastroesophageal reflux rarely occurs. About 1/3 of huge paraesophageal hiatus hernias are prone to incarceration.

3. Mixed hiatal hernia

The first two types coexist, the least common. In the mixed type, the gastroesophageal junction and the greater curvature of the stomach are laterally shifted to the diaphragm. The herniated part of the stomach is larger, reaching 1/3 of the stomach or the entire stomach, and even part of the greater omentum and colon. The chest cavity often has symptoms of acute abdomen such as incarceration, strangulation and perforation.

Most patients with this disease have different degrees of gastroesophageal reflux, and after the esophagus is squeezed by the hernia, local circulation is obstructed, so reflux esophagitis and esophageal ulcers are common. Repeated inflammation and healing can cause scarring of the esophagus. Sometimes inflammation spreads to the outside of the esophagus wall, which can cause inflammation of the esophagus. A stomach herniated into the thoracic cavity can also cause local circulatory disturbances caused by incarceration, torsion and compression of the hernia, which can lead to gastric mucosal edema, congestion, infarction, erosion, ulcers and bleeding.

This disease and reflux esophagitis are mutually causal and mutually promoting. In the middle and late stages of reflux esophagitis, due to esophageal inflammation, erosion and ulcers, the esophagus is shortened, and the gastroesophageal junction is pulled up and moved into the chest cavity. Hiatal hernia is formed; and in hiatal hernia, the His angle formed between the esophagus and the stomach changes from an acute angle to an obtuse angle, the ligament around the hiatus is loosened, and the hiatal hernia itself can also relax the lower esophageal sphincter (LES) and resist reflux Mechanism destruction, leading to reflux

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