Noninvasive Positive Pressure Ventilation (NIPPV)-Associated Expanding Hiatal Hernia Causing Pulmonary Tamponade: A Case Report on Unusual Complication of NIPPV
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Numerous diseases related to gastric distension have been found and shown to be linked with noninvasive positive pressure ventilation (NIPPV). We describe the case of a 93-year-old female who came with progressively worsening shortness of breath that initially responded to NIPPV but subsequently deteriorated. Imaging revealed gaseous distension of a preexisting hiatal hernia with air-fluid levels and compressive effects on the left lower lobe of the lung. She was successfully managed using a conservative decompression strategy. This is the first case to our knowledge of NIPPV causing considerable distension of an existing hiatal hernia to the point of mediastinal tamponade.Keywords:
Hiatal Hernia
Gastric distension
Hiatal Hernia
Potential difference
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Hiatal Hernia
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Changes in gastric motility induced by distension of the stomach were studied electromyographically in anesthetized dogs. In vagotomized dogs, gastric distension decreased the electrical control activity (ECA) frequency. The magnitude of this decrease was correlated with the degree of gastric distension; its' frequency decreased from 4.7 to 3.5 Hz/min with 400 ml distension. In splanchnicectomized dogs, 400 ml gastric distension also evoked a decrease in ECA frequency from 3.9 to 2.9 Hz/min. In vagotomized and spinal transected dogs, 400 ml distension of the stomach evoked a decrease in ECA frequency from 4.3 to 3.4 Hz/min. In the vagotomized and splanchnicectomized dogs, ECA frequency decreased from 5.0 to 3.4 Hz/min with 400 ml distension. These values were similar to those of the intact stomach previously reported. The results of the present study suggest that the extrinsic autonomic nervous system does not contribute significantly to regulation of the ECA frequency following gastric distension in anesthetized dogs.
Gastric distension
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It is not known which region of the stomach is responsible for symptom generation or whether symptoms induced by gastric distension are region specific. Also, it is unclear whether low level gastric distension has a modulatory role on gastric tone and mechanosensitivity.To define differences in the sensorimotor response to distension between proximal and distal gastric distension, and to determine the effects of low level gastric distension on gastric tone and mechanosensitivity.In 14 healthy volunteers, a double barostat assembly incorporating a distal (antral) and proximal (fundic) bag was introduced into the stomach. Pressure sensitivity tests with either bag were performed with and without simultaneous background distension of the other bag in a randomised manner. Proximal gastric accommodation to a meal was measured with and without simultaneous distal gastric distension.The distal stomach was less compliant than the proximal stomach to low level distension. Thresholds for first perception and discomfort, and symptom profiles did not differ between distal and proximal gastric distension. Simultaneously applied low level gastric distension of one segment did not affect gastric mechanosensitivity of the other segment. Both the proximal and distal stomach relax after ingestion of a meal. Simultaneous low level antral distension decreases proximal gastric accommodation to a meal.Compared with the proximal stomach, the distal stomach is less compliant but its mechanosensitivity is not different. Symptoms induced by gastric distension are not region specific and no spatial summation occurred. Meal induced relaxation occurs both in the proximal and distal stomach.
Gastric distension
Barostat
Pyloric Antrum
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Cricoid pressure
Gastric distension
Rapid sequence induction
Cricoid cartilage
Hiatal Hernia
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The lower esophageal sphincter (LES) and its surrounding structures normaly act as a reflux barrier between the esophagus and the stomach preventing the abnormal exposure of the gullet to the gastric contents. Gastroesophageal reflux disease (GERD) is common and is apparently being detected at an ever-increasing rate in the western world. Symptoms of GERD affect 19% of adults in the US on a weekly basis and have a significant negative impact on patients QoL. To date, transient lower esophageal sphincter relaxations (TLESRs) triggered by gastric distension and mediated by a vagovagal reflex are considered the most important mechanism for reflux in up to 80% of the cases of normal and GERD patients. In the most severe cases (<20%) the LES pressure is low or absent and demonstrates little resistance to reflux. Reflux and its concequences may be further aggravated in the presence of a large hiatal hernia that is associated with increased frequency of TLESRs and impaired esophageal clearance.
Gastric distension
Esophageal sphincter
Hiatal Hernia
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Numerous diseases related to gastric distension have been found and shown to be linked with noninvasive positive pressure ventilation (NIPPV). We describe the case of a 93-year-old female who came with progressively worsening shortness of breath that initially responded to NIPPV but subsequently deteriorated. Imaging revealed gaseous distension of a preexisting hiatal hernia with air-fluid levels and compressive effects on the left lower lobe of the lung. She was successfully managed using a conservative decompression strategy. This is the first case to our knowledge of NIPPV causing considerable distension of an existing hiatal hernia to the point of mediastinal tamponade.
Hiatal Hernia
Gastric distension
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The question was examined as to whether or not lower esophageal sphincter pressure (LESP) rises in response to increases in intragastric pressure. Pressure profiles of the lower esophageal sphincter (LES) were recorded with low compliance rapid pull-through manometry, in 9 healthy volunteers without hiatal hernia. Fundic pressure was increased by inflating the stomach with air. Air insufflation was stopped when gastric distension became painful (at 8.4 mm Hg +/- 0.7 SEM). No subject had nausea. Mean resting LESP was 24.6 mm Hg +/- 2.2 SEM. There was a negative linear relationship between fundic pressure and LESP: LESP decreased by 1.10 +/- 0.15 SEM per 1 mm Hg fundic pressure rise. On the average, the sum of fundic pressure and LESP remained constant. Thus, there is not only a lack of reflex contraction of LES in response to fundic pressure rise, but actually a weakening of the LES by fundic distension. This mechanism might facilitate belching following swallowing of air.
Gastric distension
Hiatal Hernia
Esophagogastric junction
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Hiatal Hernia
Gastric distension
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Increased esophagogastric junction distensibility has been implicated in the development of gastroesophageal reflux disease (GERD). Previous authors have demonstrated a reduction in distensibility following anti-reflux surgery, but the changes during the operation are not clear. Our study aimed to ascertain the feasibility of measuring intraoperative distensibility changes and to assess if this would have potential to modify the operation. Seventeen patients with GERD were managed in a standardized manner consisting of preoperative assessment with symptom scoring, endoscopy, 24 hours pH studies, and manometry. Patients then underwent laparoscopic Nissen fundoplication with intraoperative distensibility measurement using an EndoFLIP EF-325 functional luminal imaging probe (Crospon Ltd, Galway, Ireland). This device utilizes impedance planimetry technology to measure cross-sectional area and distensibility within a balloon-tipped catheter. This is inflated at the esophagogastric junction to fixed distension volumes. Thirty-second median cross-sectional area and intraballoon pressure measurements were recorded at 30 and 40 mL balloon distensions. Measurement time points were initially after induction of anesthesia, after pneumoperitoneum, after hiatal mobilization, after hiatal repair, after fundoplication, and finally pre-extubation. Postoperatively, patients continued on protocol and were discharged after a two-night stay tolerating a sloppy diet. Patients with a hiatus hernia on high-resolution manometry had a significantly higher initial esophagogastric junction distensibility index (DI) than those without. Hiatus repair and fundoplication resulted in a significant overall reduction in the median DI from the initial to final recordings (30 mL balloon distension reduction of 3.26 mm(2) /mmHg (P = 0.0087), 40 mL balloon distension reduction of 2.39 mm(2) /mmHg [P = 0.0039]). There was also a significant reduction in the DI after pneumoperitoneum, hiatus repair, and fundoplication at 40 mL balloon distension. Two individual cases in the series highlight the utility of the system in potentially changing the operation. After fundoplication, patient 7 recorded a DI of 0.47 mm(2) /mmHg, the lowest in our series, and subsequently required reoperation because of significant symptoms of dysphagia. Patient 12 had a fundoplication that appeared visually too tight and was converted intraoperatively to a Lind 270° wrap resulting in a change in the DI from 0.65 to 0.89 mm(2) /mmHg. Laparoscopic Nissen fundoplication results in a significant reduction in the distensibility of the esophagogastric junction. The EndoFLIP system is able to demonstrate significant changes during the operation and may help guide intraoperative modification. Larger multicenter studies with long-term follow up would be beneficial to develop a target range of distensibility associated with good outcome.
Hiatal Hernia
Nissen fundoplication
Esophagogastric junction
Gastric distension
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