GORD and hiatus hernia Flashcards
(149 cards)
1
Q
What is the definition of gastro-oesophageal reflux?
A
Some degree of reflux is physiological. Reflux is a normal process, and is often asymptomatic. Pathological reflux is when abnormal exposure of the oesophagus to gastric acid leads to symptoms or mucosal injury.
2
Q
What is the epidemiology of GORD in Western society?
A
10-20% experience weekly symptoms, probably associated with lifestyle risk factors rather than genetic factors.
3
Q
What is the incidence of GORD in East Asia?
A
The lowest incidence is 5%.
4
Q
How is the incidence of GORD changing over time?
A
The incidence is increasing over time.
5
Q
What is the pathophysiology of normal reflux events?
A
Small amounts of reflux events are normal and generally asymptomatic.
6
Q
What can cause symptoms of GORD?
A
Symptoms can result from inappropriate relaxation of the lower oesophageal sphincter in the absence of peristaltic contraction of the oesophagus, or due to lowering of lower oesophageal sphincter pressure.
7
Q
What is the role of the lower oesophageal sphincter (LOS) in preventing reflux?
A
Functional lower oesophageal sphincter mechanism prevents pathological reflux.
8
Q
What creates a physiological high pressure zone in the oesophagus?
A
Intrinsic musculature tone of the oesophagus.
9
Q
How do muscles in the oesophagus function during swallowing?
A
Muscles in a state of tonic contraction relax to allow passage of food bolus.
10
Q
What are sling fibres of the gastric cardia?
A
Fibres oriented diagonally from cardia-fundus junction to the lesser curve of the stomach, functions to increase pressure.
11
Q
What is the function of the crura of the diaphragm?
A
Surround the oesophagus as it passes through the oesophageal hiatus and compress the oesophagus during inspiration.
12
Q
What is positive pressure intra-abdominal oesophagus?
A
When the gastro-oesophageal junction is anchored within the abdominal cavity, increased intra-abdominal pressure relative to intrathoracic pressure compresses the intra-abdominal portion of the oesophagus.
13
Q
What is the angle of His?
A
The angle of the oesophagus as it enters the cardia, acting as a flap valve.
14
Q
Fill in the blank: Pathological reflux leads to _______.
A
[symptoms or mucosal injury]
15
Q
What is the role of acid clearance in mucosal defence?
A
Acid clearance involves persistalsis and gravity during the day
16
Q
What does cellular buffering of acid refer to?
A
Cellular buffering of acid helps maintain pH balance in the mucosal environment
17
Q
What are the two main categories in the Montreal Classification of GORD?
A
Oesophageal and Extra-esophageal syndromes
This classification helps in understanding the different manifestations of GORD.
18
Q
How does the Montreal Classification further divide syndromes?
A
Depending on symptoms, complications, and whether associations are established or proposed
This division is useful for creating a tree diagram of the conditions.
19
Q
What are the symptomatic oesophageal syndromes listed in the Montreal Classification?
A
- Typical reflux syndrome
- Reflux chest pain syndrome
- Non Erosive Reflux Disease (NERD)
- Hypersensitivity
These syndromes are characterized by the presence of symptoms without significant oesophageal injury.
20
Q
What are the syndromes with oesophageal injury according to the Montreal Classification?
A
- Oesophagitis
- Stricture
- Barrett’s Oesophagus
- Adenocarcinoma
These conditions indicate damage to the oesophagus due to reflux.
21
Q
What are the established associations of extra-oesophageal syndromes?
A
- Reflux cough
- Reflux laryngitis
- Reflux asthma
- Reflux dental erosions
These conditions show a clear relationship with gastro-oesophageal reflux.
22
Q
What are the proposed associations of extra-oesophageal syndromes?
A
- Pharyngitis
- Sinusitis
- Idiopathic pulmonary fibrosis
- Recurrent otitis media
These associations are suggested but not definitively established.
23
Q
What characterizes Grade A reflux oesophagitis?
A
One or more mucosal breaks <5mm in maximal length
This grade indicates minimal damage to the esophageal lining.
24
Q
What defines Grade B reflux oesophagitis?
A
One or more mucosal breaks >5mm but without continuity across mucosal folds
This grade shows more significant damage than Grade A.
25
What is the criterion for Grade C reflux oesophagitis?
Mucosal breaks continuous between > mucosal folds but involving <75% oesophageal circumference
## Footnote
This grade indicates extensive damage but not complete circumferential involvement.
26
What indicates Grade D reflux oesophagitis?
Mucosal breaks >75% oesophageal circumference
## Footnote
This grade represents the most severe form of reflux oesophagitis.
27
What does the Los Angeles grading classify?
Oesophagitis, from grades A-D
28
What is the primary cause of oesophagitis?
Failure of natural anti-reflux mechanisms
## Footnote
See pathophysiology for more details.
29
What are the non-modifiable risk factors for oesophagitis?
* Genetic factors (family history increases risk)
* Age >55 (marginal increase)
* No consistent association between gender and GORD
## Footnote
GORD stands for Gastro-Oesophageal Reflux Disease.
30
List the modifiable risk factors for oesophagitis.
* Dietary/lifestyle factors
* Tobacco smoking
* Alcohol intake
* Obesity
## Footnote
These factors can be altered to reduce the risk of oesophagitis.
31
How does tobacco smoking contribute to oesophagitis?
Causes coughing and deep inspiration
## Footnote
This can exacerbate reflux symptoms.
32
What effect does alcohol intake have on oesophagitis?
Reduces LOS pressure and causes direct irritation
## Footnote
LOS stands for Lower Oesophageal Sphincter.
33
What impact does obesity have on oesophagitis?
* Impaired LOS pressure
* Increased intra-abdominal pressure
* Delayed gastric emptying
## Footnote
These factors contribute to reflux and inflammation.
34
What medical conditions are risk factors for oesophagitis?
* Diabetes mellitus
* Medications (anticholinergic medications, Ca channel blockers, nitrates)
## Footnote
Certain medications can affect esophageal motility and pressure.
35
What gastric/mechanical factors can lead to oesophagitis?
* Loss of antireflux mechanisms
* Presence of hiatus hernia
* Increased acid production
* Reduced gastric emptying
* Raised intra-abdominal pressure
## Footnote
Examples include pregnancy or tumors.
36
What syndrome is associated with increased acid production leading to oesophagitis?
Zollinger-Ellison syndrome
## Footnote
This syndrome causes gastrin-secreting tumors, leading to excessive gastric acid.
37
What conditions can result in reduced gastric emptying?
* Distal obstruction (pyloric stenosis)
* Gastroparesis
## Footnote
These conditions can delay food passage and increase reflux.
38
What is the potential protective role of H. pylori in oesophagitis?
Reduced acid due to atrophic gastritis
## Footnote
H. pylori infection is often associated with gastric conditions.
39
What is the most common typical symptom of oesophagitis?
Heartburn (80%) - burning sensation, retrosternal most commonly post-prandial and often at night.
## Footnote
Heartburn is a common symptom associated with acid reflux.
40
What percentage of patients experience regurgitation as a symptom of oesophagitis?
54% - perception of gastric content flowing up oesophagus (hot, waterbrash, regurgitated food).
## Footnote
Regurgitation is often described as the sensation of food or liquid coming back up.
41
What is waterbrash?
A symptom associated with oesophagitis characterized by a sudden increase in saliva production.
## Footnote
Waterbrash is often linked to acid reflux.
42
Define odynophagia.
Painful swallowing often associated with oesophagitis.
## Footnote
Odynophagia can be a significant indicator of inflammation in the esophagus.
43
What is dysphagia?
Difficulty swallowing.
## Footnote
It can be a symptom of various esophageal disorders, including oesophagitis.
44
List two atypical symptoms of oesophagitis.
* Chest pain - GORD related angina
* Epigastric/abdominal pain
## Footnote
Atypical symptoms may not directly relate to the esophagus but can indicate underlying issues.
45
What are some extra-oesophageal symptoms of oesophagitis?
* Cough
* Shortness of breath (SOB)
* Wheeze
* Pulmonary disease
## Footnote
These symptoms indicate that acid reflux can affect respiratory function.
46
What laryngeal symptoms can occur with oesophagitis?
* Hoarseness
* Throat clearing
* Throat pain
* Globus sensation
* Choking
* Postnasal drip
* Laryngeal/tracheal stenosis
* Laryngospasm
## Footnote
Laryngeal symptoms can arise due to acid exposure affecting the throat and voice box.
47
What are alarm symptoms that require further investigation in cases of oesophagitis?
* UGI bleeding
* Weight loss
* Progressive dysphagia
* Respiratory symptoms
* Chest pain
## Footnote
Alarm symptoms indicate a potentially serious underlying condition that may need urgent medical attention.
48
What investigation methods can be used for oesophagitis?
OGD (Oesophago-gastro-duodenoscopy) or other investigations as required.
## Footnote
OGD is a common procedure used to visualize the upper gastrointestinal tract.
49
What is a presumptive diagnosis in oesophagitis, and when can this be made?
A presumptive diagnosis can be made in presence of typical symptoms (heartburn and regurgitation) and empiric therapy with PPI can be commenced.
## Footnote
Response to treatment is not great in terms of sensitivity or specificity compared to pH study.
50
What should be considered to exclude alternative causes of oesophagitis?
Consider diagnosis of cardiac or biliary pathology and rule out cancer.
## Footnote
Atypical symptoms may require referral to another specialty.
51
What is the role of endoscopy in diagnosing oesophagitis?
Endoscopy is used to exclude other pathology, most importantly cancer in high-risk patients, and to assess evidence of mucosal injury and complications.
## Footnote
It can also help diagnose Barrett's and adenocarcinoma.
52
What are the indications for endoscopy in patients with oesophagitis?
Recommended for all patients with:
* Alarm features
* Bleeding
* Anaemia
* Dysphagia
* Weight loss
* New onset dyspepsia in patients >55 years
* Refractory symptoms age >55
## Footnote
In reality, endoscopy is used much more frequently.
53
What is the significance of finding Barrett’s or Grade C/D reflux oesophagitis during endoscopy?
Presence of Barrett’s or Grade C/D reflux oesophagitis is diagnostic of pathological reflux.
## Footnote
It can also provide clues about underlying dysmotility.
54
What percentage of patients with reflux symptoms have normal endoscopy results?
2/3 of patients with reflux symptoms have normal endoscopy results, a condition known as Non Erosive Reflux Disease (NERD).
55
What is the gold standard for diagnosing and quantifying acid reflux?
24h pH monitoring is the gold standard for diagnosis and quantification of acid reflux.
56
Who should undergo pH studies?
Indications include:
* Typical reflux symptoms refractory to PPI
* Atypical symptoms where diagnosis is in doubt
* Prior to surgery.
## Footnote
Routine use is not recommended.
57
How is pH monitoring performed?
Performed off acid suppression using a thin catheter with solid state electrodes positioned 5cm above the lower oesophageal sphincter (LOS).
58
What variables are recorded during pH studies?
Variables include:
* Total time pH <4 (%)
* Upright time pH <4
* Supine time pH <4
* Number of episodes
* Longest episode
## Footnote
Normal values for total time pH <4 is <5%, upright time <8%, and supine time <3%.
59
What is the DeMeester score?
Composite score used in pH studies; normal value is <14.72.
60
What does a Symptom Index (SI) greater than 50% indicate?
SI >50% is positive, indicating a correlation of symptoms with reflux.
61
What does a Symptom Sensitivity Index (SSI) greater than 10% indicate?
SSI >10% is positive, indicating a high correlation between reflux episodes and reported symptoms.
62
What is the purpose of impedance monitoring?
Measures resistance to alternating current to differentiate between liquid and air contents in the lumen, improving sensitivity and specificity when combined with pH monitoring.
63
What is the gold standard test to assess motor function before reflux surgery?
Manometry is the gold standard test to assess motor function and should be done before reflux surgery.
64
What does manometry evaluate?
Evaluates:
* Resting LOS pressure
* Relaxation of LOS
* Peristalsis of oesophageal body.
## Footnote
Resting LOS pressure should be between 12-30mmHg.
65
How are barium swallows used in the context of oesophagitis?
Barium swallows show anatomic problems (strictures, pouches, tumours) and functional issues (achalasia).
66
Is barium swallow testing complementary or necessary with the use of endoscopy and pH/manometry studies?
Barium swallows are considered complementary but unnecessary due to the widespread use of endoscopy and pH/manometry studies.
67
What is the first step in managing oesophagitis?
Lifestyle changes
## Footnote
This includes reducing risk factors such as smoking cessation, weight loss, and avoiding certain food triggers.
68
List some lifestyle modifications recommended for patients with oesophagitis.
* Smoking cessation
* Weight loss
* Avoiding triggers (EtOH, caffeine, fatty food, spicy food)
* Elevation of head of bed
* Eating small meals more frequently
* Avoid going to bed with a full stomach
## Footnote
These measures are often ineffective for patients with moderate-severe symptoms.
69
What is the role of proton pump inhibitors (PPIs) in the treatment of oesophagitis?
Irreversibly block the H+/K+ ATPase of gastric parietal cells
## Footnote
Examples include omeprazole and pantoprazole.
70
What is the effect of 20mg and 40mg daily doses of PPIs?
* 20mg daily reduces gastric acid production by 90%
* 40mg daily reduces gastric acid production by 95% (not a significant increase)
## Footnote
PPIs increase gastric pH from <2 to >3.
71
When can PPIs be discontinued in patients with mild symptoms?
After 8 weeks if symptoms respond well
## Footnote
Severe symptoms may require long-term use.
72
What are some risks associated with long-term use of PPIs?
* Reduced calcium absorption
* Hip fractures
* Community-acquired pneumonia
* Low magnesium levels
## Footnote
These risks should be considered when prescribing PPIs long-term.
73
What is the mechanism of action for H2 antagonists?
Reversible antagonism of H2 receptors on gastric parietal cells
## Footnote
Examples include famotidine and ranitidine.
74
Why are H2 antagonists less commonly used as first-line therapy?
Less effective than PPIs
## Footnote
This leads to their reduced use in managing oesophagitis.
75
What are the indications for considering surgical treatment in oesophagitis?
* Moderate-severe GORD symptoms
* Objective evidence of reflux (endoscopic or pH testing)
* Good symptom and reflux correlation
## Footnote
Surgical intervention may be required if medical management fails.
76
What could indicate a failure to respond to medication in oesophagitis patients?
* Increased dose of PPIs
* Lack of response to lifestyle modifications
* Symptoms controlled by medication but with side effects or intolerance
## Footnote
This may suggest an alternative diagnosis or predict surgery failure.
77
Is Barrett's esophagus an indication for surgery?
No, it is not an indication for surgery
## Footnote
Surgery should be based on symptoms, not on Barrett's alone.
78
What is the primary goal of surgical treatment for oesophagitis?
Prevent reflux while preserving the patient's ability to swallow normally
## Footnote
This is achieved by restoring normal lower esophageal sphincter (LOS) pressure and correcting any associated hiatus hernia.
79
Describe the mechanism of the surgical creation of a floppy valve.
Maintaining apposition of abdominal oesophagus and gastric fundus
## Footnote
This allows for compression of the intra-abdominal oesophagus as gastric pressure rises.
80
True or False: An increase in LOS pressure is crucial for surgical effectiveness.
False
## Footnote
Some partial wraps do not increase pressure yet remain effective.
81
What are the surgical options for the management of GORD?
Fundoplication, Gastroplasty, Approaches, Access
## Footnote
GORD stands for Gastro-Oesophageal Reflux Disease.
82
What are the two types of fundoplication?
Total - Nissen, Partial - Anterior, Posterior
## Footnote
Fundoplication is a surgical procedure to treat GORD.
83
What are the types of gastroplasty?
Collis, Hills
## Footnote
Gastroplasty is another surgical option for managing GORD.
84
What are the approaches for surgical management of GORD?
Transabdominal, Transthoracic
## Footnote
These approaches refer to the surgical access routes.
85
What are the access methods for surgical options in GORD management?
Lap, Open
## Footnote
Access methods refer to the type of incision used during surgery.
86
What is Fundoplication?
A surgical procedure to treat gastroesophageal reflux disease (GERD) by wrapping the top of the stomach around the lower esophagus
87
What are predictors of success for Fundoplication?
Objective pre-op evidence of reflux, complete/partial response with PPI, good compliance with antireflux meds
88
What are the goals of Fundoplication?
Reduction of Hiatus hernia, tension free restoration of intraabdominal oesophageal length (>3cm), repair crura, perform fundoplication
89
What are the basic elements of Fundoplication?
* Exposure of hiatus
* Reduction of HH
* Complete mobilisation of GOJ
* Exposure of 3-4cm of oesophagus below the diaphragm (without tension)
* Crural closure
* Fundus mobilisation
* Creation of a short (<2cm), loose wrap (+/- over 56Fr Bougie)
* Preservation of vagi
90
What are the types of Fundoplication?
* Nissen – 360 degree wrap
* Toupet – posterior 270 degree wrap
* Dor – anterior 180 degree wrap
91
What is the difference in incidence of recurrent reflux between Nissen and posterior partial wraps?
Incidence of recurrent reflux is similar
92
What are the benefits of Laparoscopic Fundoplication compared to open surgery?
* Reduced overall morbidity
* Quicker recovery
* Less incisional hernia
* Equivalent anti-reflux effects and side effects at 15 years
93
What are general complications associated with Fundoplication?
* Bleeding
* Infection
* VTE
* Death
94
What are early minor complications of Fundoplication?
* Inability to belch
* Early satiety
* Pneumothorax – 2%
* Perforation of oesophagus or stomach – 1%
* Vascular injury
95
What are late complications of Fundoplication?
* Wrap too tight
* Dysphagia
* Gas Bloat syndrome
* Wrap too loose
* Paraoesophageal hernia
* Recurrence of symptoms, need for medication ~ 10-15%
* Wrap slipped
* Bilobed Stomach
96
What is Roux-en-Y bypass and when is it used?
A surgical option in morbidly obese patients that provides excellent improvement in reflux
97
What are some endoscopic procedures related to Fundoplication?
* Radiofrequency (Stretta procedure)
* Polymer injection
* Enteryx
* Endoclinch
* Procedures to produce a partial fundoplication (EsophyX, MUSE)
98
True or False: None of the endoscopic approaches achieve the level of reflux control associated with surgical fundoplication.
True
99
What is the natural history of oesophagitis?
The natural history includes the development of oesophageal stricture and the potential for Barrett’s oesophagus.
## Footnote
Oesophageal stricture can be associated with conditions like Schatzki’s ring.
100
What percentage of GORD patients may exhibit concentric thickening at the gastro-oesophageal junction?
2-10%
## Footnote
This thickening is not always pathological.
101
What must always be excluded when diagnosing oesophageal stricture?
Malignancy
102
What is Barrett’s oesophagus?
A condition related to oesophagitis that requires monitoring due to potential malignancy risk due to the metaplasia - dysplasia - malignancy chain of events seen in patients with Barretts.
103
Compare medical therapy and surgical therapy for oesophagitis.
Both have a similar response rate (90%) at up to 3 years, but surgery may provide better long-term control >5 years.
## Footnote
This includes both pH studies and symptoms.
104
What do most patients believe about the benefits of surgery compared to its downsides?
The benefits of surgery in terms of reflux control far outweigh the downsides.
105
What percentage of patients will develop recurrent hiatal hernia (HH) after surgery?
25%
106
What do 75% of patients with recurrent reflux experience post-surgery?
They find it is not as bad as pre-op and can control it with medication.
107
What percentage of patients with recurrence may require re-do surgery due to bad reflux?
25%
108
What is Type I hiatus hernia?
Sliding hernia (90% prevalence) where displacement of GOJ occurs above the diaphragm, but the stomach stays in usual alignment with the fundus below GOJ. Phreno-oesophageal ligament is attenuated but intact.
## Footnote
GOJ stands for gastro-oesophageal junction.
109
What characterizes Type II hiatus hernia?
Paraoesophageal hernia (3% prevalence) where the GOJ remains within the abdomen and the gastric fundus herniates into the thoracic cavity, with the fundus above the GOJ.
## Footnote
This type is less common than Type I.
110
What is a Type III hiatus hernia?
Combined hernia where both the GOJ and fundus herniate through a defect in the phrenoesophageal membrane, resulting in an enlargement of a type I defect to allow the fundus into the thorax.
## Footnote
This type is a combination of the features of Type I and Type II.
111
Describe Type IV hiatus hernia.
Large defect with other organs within the sac, most commonly involving the transverse colon.
## Footnote
This type indicates a more severe herniation involving multiple organs.
112
What is a giant hiatus hernia?
No real agreed upon definition; some would say all type 4 hernias.
113
What percentage of the stomach must be within the thorax on imaging to classify as a giant hiatus hernia?
>50%
114
What is the measurement criteria for a hernia to be considered a giant hiatus hernia during endoscopy?
Measures >6cm in length
115
What is the crural defect size at operation that indicates a giant hiatus hernia?
>5cm
116
What percentage of patients with giant hiatus hernia are asymptomatic?
At least 50%
117
What are common symptoms associated with giant hiatus hernia?
* GORD
* Chest/epigastric pain
* Postprandial fullness
* Vomiting
118
What are some severe complications of giant hiatus hernia?
* Bleeding (Gastritis, oesophagitis, erosions)
* Cameron’s ulcer
* Respiratory compromise
119
What is Cameron’s ulcer?
Linear erosions that can form at the level of the diaphragm, potentially causing IDA.
120
What respiratory issue can occur due to a giant hiatus hernia?
Respiratory compromise due to mass stomach in chest.
121
What serious condition can a giant hiatus hernia lead to?
Gastric volvulus
122
What is Borchardt triad?
* Severe epigastric pain
* Retching and inability to vomit
* Inability to pass NG tube
123
What can gastric outlet obstruction progress to in the context of giant hiatus hernia?
Ischaemia.
124
What imaging techniques are mentioned for investigating a hiatus hernia?
CXR, CT, Barium study, Endoscopy
## Footnote
These techniques help visualize the anatomy and assess the hernia.
125
How is a hiatus hernia measured?
Length of separation between Z-line to diaphragmatic impressions
## Footnote
The Z-line refers to the squamous-columnar junction.
126
What factors determine the management of a hiatus hernia?
Clinical presentation and type of hernia
## Footnote
Management varies depending on symptoms and hernia classification.
127
What are acute indications for surgery in hiatus hernia management?
Acute gastric volvulus, uncontrolled bleeding, strangulation, perforation, respiratory compromise
## Footnote
These conditions may require immediate surgical intervention.
128
What is the mortality risk of emergency surgery for hiatus hernia?
Approximately 5%
## Footnote
This risk highlights the seriousness of emergency interventions.
129
What is the management approach for asymptomatic sliding type 1 hernias?
May not indicate elective repair
## Footnote
Truly asymptomatic hernias typically do not require surgery.
130
What should be considered for symptomatic sliding type 1 hernias?
Best medical management of GORD symptoms, failure of non-operative management may lead to surgical repair
## Footnote
GORD refers to gastroesophageal reflux disease.
131
What is the recommendation for symptomatic type II-IV paraesophageal hernias?
All symptomatic type II-IV hernias should be repaired
## Footnote
This is based on the risks associated with these types of hernias.
132
What does recent 'watchful waiting' studies indicate for type II-IV hernias?
Risk of emergency surgery is 1.2% at 6.5 years
## Footnote
This suggests that some cases may not require immediate surgery.
133
What is included in the pre-operative evaluation for hiatus hernia?
History, examination, endoscopy, barium swallow, further testing (e.g., manometry, pH testing)
## Footnote
These steps help assess the condition and rule out other pathologies.
134
What are the principles of surgical management for hiatus hernia?
Excision of hernia sac, reduction of herniated stomach + 2-3cm of esophagus, repair of diaphragmatic hiatus
## Footnote
These principles guide the surgical approach.
135
What surgical approaches are described for hiatus hernia repair?
Transthoracic, transabdominal, laparoscopic
## Footnote
Laparoscopic approach has become standard due to reduced morbidity.
136
What is the standard suture material for crural repair?
0 ethibond suture
## Footnote
This material is commonly used for closing the diaphragm.
137
What is the role of mesh in hiatus hernia repair?
Variable use to reinforce repair
## Footnote
Bioprosthetic mesh may be shaped and positioned to prevent erosion.
138
What is the risk of reflux after fundoplication?
20-40%
## Footnote
Fundoplication is performed to mitigate this risk.
139
What is the first type of gastric volvulus?
Organoaxial - Rotated
140
What is the second type of gastric volvulus?
Mesenteroaxial - Flipped
141
What is the initial management step for gastric volvulus?
Attempt NG insertion
142
What is the purpose of IVF in the management of gastric volvulus?
Rehydration
143
What is the ideally preferred method for repair of gastric volvulus?
Laparoscopic repair
144
What is involved in the reduction of a hernia during gastric volvulus management?
Release of volvulus
145
What should be done with non-viable tissue during the management of gastric volvulus?
Debridement
146
What is the procedure for closing the hiatal defect in gastric volvulus management?
Hiatal closure
147
What surgical procedure may be performed to prevent reflux during gastric volvulus management?
Fundoplication
148
What approach is recommended if acute peritonitis is present?
Open approach recommended
149
What should be considered for high-risk patients in the management of gastric volvulus?
Endoscopic PEG gastropexy
