You are on page 1of 8

Introduction

A hiatal hernia is an anatomical abnormality in which part of the stomach protrudes through the diaphragm and up into the chest. Hiatal hernias are a common condition seen most

often in adults over the age of 50.


Normally, the esophagus or food tube passes down through the chest, crosses the diaphragm, and enters the abdomen through a hole in the diaphragm called the esophageal hiatus. Just below the diaphragm, the esophagus joins the stomach. In individuals with hiatal hernias, the opening of the esophageal hiatus (hiatal opening) is larger than normal, and a portion of the upper stomach slips up or passes (herniates) through the hiatus and into the chest. Although hiatal hernias are occasionally seen in infants where they probably have been present from birth, most hiatal hernias in adults are believed to have developed over many years.

A hiatus hernia or hiatal hernia is the protrusion (or herniation) of the upper part of the stomach into the thorax through a tear or weakness in the diaphragm. There are two main types of hiatal hernia: 1. Sliding hiatal hernia - The gastroesophageal junction moves up through the esophageal hiatus along with some of the stomach. Although in some patients with this condition the gastroesophageal junction can reside permanently in the thorax, most patients only have a temporary herniation when they swallow. In these patients, the esophageal hiatus has been weakened or the esophagus itself has become shortened, and so contraction of the esophagus upon swallowing pulls the gastroesophageal junction and a piece of stomach temporarily through the esophageal hiatus. After swallowing, the gastroesophageal junction and stomach return to their normal position in the abdomen. This type of hiatal hernia accounts for approximately 95% of hiatal hernias, and is less serious than the para-esophageal hiatal hernia. 2. Rolling or Para-esophageal hiatal hernia - In contrast to a sliding hiatal hernia, the para-esophageal hernia involves a gastroesophageal junction that stays where it belongs in the abdomen, but has a part of the stomach, usually the fundus, that passes through the hiatus into the thorax. These hernias remain in the chest at all times and are not returned to a normal position by swallowing. Para-esophageal hiatal hernias are typically more problematic due to the pressure they put on the esophagus and the constriction placed on the herniated piece of stomach by the diaphragm.

A third kind is also sometimes described, and is a combination of the first and second kinds

SCHEMATIC DIAGRAM OF DIFFERENT TYPES OF HIATUS HERNIA. Green is the esophagus, red is the stomach, purple is the diaphragm, blue is the HIS-angle. A is the normal anatomy, B is a pre-stage, C is a sliding hiatal hernia (the LES protrudes above the diaphragm along with the stomach), and D is a paraesophageal type (the LES remains stationary but the stomach protrudes above the diaphragm).

WHEN DOES HIATAL HERNIA OCCURS? Food enters the body through the mouth and travels down the esophagus. The esophagus or food tube passes down through the chest, crosses the diaphragm, and enters the abdomen (abdominal cavity) via an opening in the diaphragm called the esophageal hiatus. The esophagus then connects with the stomach just below the diaphragm. A hiatal hernia occurs when the upper part of the stomach pushes through an opening in the diaphragm, and up into the chest. This opening is called an esophageal hiatus or diaphragmatic hiatus. Studies have shown that the opening in the diaphragm, where the esophagus connects with the stomach, acts as an additional sphincter around the lower part of the esophagus. Normally, the hiatus and the lower esophageal sphincter (LES) rely on each other to keep stomach contents from backing up into the esophagus. It is believed that a hiatal hernia can weaken the LES, and make it easier for stomach acid to back up into the esophagus.

CAUSE It is thought that hiatal hernias are caused by a larger-than-normal esophageal hiatus, the opening in the diaphragm through which the esophagus passes from the chest into the abdomen; as a result of the large opening, part of the stomach "slips" into the chest. Other potentially contributing factors include: 1. A permanent shortening of the esophagus (perhaps caused by inflammation and scarring from the reflux or regurgitation of stomach acid) which pulls the stomach up. 2. An abnormally loose attachment of the esophagus to the diaphragm which allows the esophagus and stomach to slip upwards.

SIGNS AND SYMPTOMS Symptoms may vary according to the size and position of the hernia.

Most small Sliding hernias are asymptomatic. However, symptoms could include:

Heartburn (which is worse when bending over or lying down shortly after eating) Regurgitation (backflow of stomach contents into the back of the throat Vomiting Gastric reflux (backflow of stomach contents into the esophagus) A sour or bitter taste in the mouth Frequent belching Frequent hiccups

Paraesophael hernias also tend to be asymptomatic. However, they may include intermittent symptoms that include: Nausea Retching Chest pain radiating from below the breastbone (the sternum) Feeling of pressure in the chest A bloated feeling after eating Abdominal discomfort Abdominal pressure, especially soon after eating Discomfort or pain in the stomach Discomfort or pain in the esophagus Gas Unexplained coughing Difficulty swallowing In most cases a hiatal hernia causes no symptoms, and patients can happily live their lives never knowing they have one. Of those individuals who do experience symptoms, the pain and discomfort they feel is usually due to the reflux of stomach acid into the esophagus, air, or bile. While there are several causes of acid reflux, it does happen more frequently in the presence of hiatal hernia. RISK FACTOR The following are other risk factors that can result in a hiatus hernia: Increasing age Increased pressure within the abdomen caused by: Heavy lifting or bending over Frequent or hard coughing Hard sneezing Pregnancy and delivery Violent vomiting Straining with constipation Obesity (extra weight pushes down on the abdomen increasing the pressure)

Use of the sitting position for defecation Hereditary Smoking Drug use, such as cocaine Stress Diaphragm weakness

Other possible associations include: Pregnancy Tight clothing around the abdomen A sudden physical exertion, such as weight lifting Abdominal injury causing a hole or tear in the diaphragm Constipation or straining during bowel movements Vomiting Children with this condition are usually born with it (congenital). It is often associated with gastroesophageal reflux in infants. DIAGNOSING While a doctor may use various test to diagnose a hiatal hernia, the following tests are routinely used: Upright chest x-ray Barium x-rays, also known as barium swallow - diagnostic x-rays in which barium is used to diagnose abnormalities of the digestive tract, including hiatal hernias. Upper endoscopy (also known as esophagogastroduodenoscopy or EGD) allows the doctor to examine the inside of the patient's esophagus, stomach, and duodenum (the first part of the small intestine) with an instrument called an endoscope, a thin flexible lighted tube.

TREATMENT The goals of treatment are to relieve symptoms and prevent complications. If these measures failure to control the symptoms, or complications appear, surgical repair of the hernia may be necessary. In the case of Sliding hernias, surgery is rarely necessary. Suggestions include: Eat smaller, more frequent meals. Avoid foods and beverages that may cause acid reflux symptoms. Don't eat within three hours before going to bed. Elevate the head of your bed 4 to 8 inches. Don't wear tight clothing around your waist. Avoid bending or stooping after meals. Avoid constipation. Talk to your doctor if you have a problem with this.

Don't do any heavy lifting. Lose weight. Stop smoking. Take any medications the doctor prescribes

In the case of Para-esophageal hernias, early surgical intervention is best, given the risk of serious complications, which include: Pulmonary aspiration or pulmonary compromise due to displacement of the lung by the hernia Incarceration or strangulation of the hernia Bleeding in the setting of incarceration or gastric ulceration When the hiatal hernia is large, or is of the paraesophageal type, it is likely to cause esophageal stricture and discomfort. Symptomatic patients should elevate the head of their beds and avoid lying down directly after meals until treatment is rendered. If the condition has been brought on by stress, stress reduction techniques may be prescribed, or if overweight, weight loss may be indicated. Medications that reduce the lower esophageal sphincter (or LES) pressure should be avoided. Antisecretory drugs like proton pump inhibitors and H2 receptor blockers can be used to reduce acid secretion.

SURGICAL PROCEDURE Where hernia symptoms are severe and chronic acid reflux is involved, surgery is sometimes recommended, as chronic reflux can severely injure the esophagus and even lead to esophageal cancer. Surgery is indicated for sliding hiatal hernias that are unresponsive to medical therapy and large para-esophageal hiatal hernias. The surgical procedure used to treat hiatal hernias is called the Nissen fundoplication. In fundoplication, the gastric fundus (upper part) of the stomach is wrapped, or plicated, around the inferior part of the esophagus, preventing herniation of the stomach through the hiatus in the diaphragm and the reflux of gastric acid. The procedure is now commonly performed laparoscopically. With proper patient selection, laparoscopic fundoplication has low complication rates and a quick recovery. Complications include gas bloat syndrome, dysphagia (trouble swallowing), dumping syndrome, excessive scarring, and rarely, achalasia. The procedure sometimes fails over time requiring a second surgery to make repairs. Complications include gas bloat syndrome, dysphagia (trouble swallowing), dumping syndrome, excessive scarring, and rarely, achalasia. The procedure sometimes fails over time, requiring a second surgery to make repairs.

You might also like