hiatal hernia

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A hernia in which part of the stomach protrudes through the esophageal opening of the diaphragm. Also called hiatus hernia.

Protrusion of a part of the stomach upwards through the diaphragm. The condition occurs in about 40% of the population, most people suffering no ill-effects; in a small number of people there is reflux of stomach contents into the oesophagus, causing heartburn. See also gastro-intestinal tract.

A protrusion of a portion of the stomach upward through the diaphragm. The condition occurs in approximately 40% of individuals and most people display few, if any, symptoms. The major difficulty is gastroesophageal reflux, which is the backflow of the acid contents of the stomach into the esophagus.

Definition

A hiatal hernia is an abnormal protrusion of the stomach up through the diaphragm and into the chest cavity.

Description

A hiatal or diaphragmatic hernia is different from abdominal hernias in that it is not visible on the outside of the body. With a hiatal hernia, the stomach bulges upward through the esophageal hiatus (the hole through which the esophagus passes) of the diaphragm. This type of hernia occurs more often in women than in men, and it is treated differently from other types of hernias.

Causes & Symptoms

A hiatal hernia may be caused by obesity, pregnancy, aging, or previous surgery. About 50% of all people with hiatal hernias do not have any symptoms. For those who do have symptoms, they include heartburn, usually 30–60 minutes after a meal, or mid-chest pain due to gastric acid from the stomach being pushed up into the esophagus. The pain and heartburn are usually worse when lying down. Frequent belching and feelings of abdominal fullness may also occur.

Diagnosis

The diagnosis for a hiatal hernia is based on a person's reported symptoms. The doctor may then order tests to confirm the diagnosis. If a barium swallow is ordered, the person drinks a chalky white barium solution, which will help any protrusion through the diaphragm to show up on the x ray that follows. Currently, a diagnosis of hiatal hernia is more frequently made by endoscopy. This procedure is done by a gastroenterologist (a specialist in digestive diseases). During an endoscopy the person is given an intravenous sedative and a narrow tube is inserted through the mouth and esophagus, into the stomach where the doctor can visualize the hernia. The procedure takes about 30 minutes and may cause some discomfort, but usually no pain. It is done on an outpatient basis.

Treatment

Dietary and lifestyle adjustments to control a hiatal hernia include:

• Avoiding reclining after meals.
• Avoiding spicy foods, acidic foods, alcohol, and tobacco.
• Eating small frequent bland meals to keep pressure on the esophageal sphincter.
• Eating a high-fiber diet.
• Raising the head of the bed several inches with blocks to help both the quality and quantity of sleep.

Visceral manipulation done by a trained therapist can help return the stomach to its proper positioning. Deglycyrrhizinated licorice (DGL), helps balance stomach acid by improving the protective substances that line the stomach and intestines and by improving blood supply to these tissues. DGL does not interrupt the normal function of stomach acid.

Allopathic Treatment

There are several types of medications that help to manage the symptoms of a hiatal hernia. Antacids are used to neutralize gastric acid and decrease heartburn. Drugs that reduce the amount of acid produced in the stomach (H2 blockers) are also used. This class of drugs includes famotidine (sold under the name Pepcid), cimetidine (Tagamet), and ranitidine (Zantac). Omeprazole (Prilosec) is not an H2 blocker, but is another drug that suppresses gastric acid secretion and is used for hiatal hernias. Another option may be metoclopramide (Reglan), a drug that increases the tone of the muscle around the esophagus and causes the stomach to empty more quickly.

Expected Results

Hiatal hernias are treated successfully with medication and diet modifications 85% of the time. The prognosis remains excellent even if surgery is required in adults who are otherwise in good health.

Prevention

Some hernias can be prevented by maintaining a reasonable weight, avoiding heavy lifting and constipation, and following a moderate exercise program to maintain good abdominal muscle tone.

Resources

Books

Bare, Brenda G. and Suzanne C. Smeltzer. Brunner and Suddarth's Textbook of Medical-Surgical Nursing. 8th edition. Philadelphia: Lippincott-Raven Publishers, 1996.

Polaske, Arlene L. and Suzanne E. Tatro. Luckmann's Core Principles and Practice of Medical Surgical Nursing. Philadelphia: W.B. Saunders Company, 1996.

Periodicals

Kingsley, A.N., I.L. Lichtenstein, and W.K. Sieber. "Common Hernias In Primary Care." Patient Care. (April 1990): 98-119.

[Article by: Paula Ford-Martin]

Ventricular hernia
Classification and external resources
ICD-10	K44., Q40.1
ICD-9	553.3, 750.6
OMIM	142400
DiseasesDB	29116
MedlinePlus	001137
eMedicine	med/1012  radio/337
MeSH	D006551

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.

Contents 1 Symptoms 2 Risk factors 3 Diagnosis 4 Types 5 Treatment 6 Complications 7 Epidemiology 8 Notes and references 9 External links

Symptoms

The symptoms include acid reflux, and pain, similar to heartburn, in the chest, and upper stomach.

In most patients, hiatus hernias cause no symptoms. Sometimes patients experience heartburn and regurgitation, when stomach acid refluxes back into the esophagus.

Risk factors

The following are risk factors for having a hiatus hernia.

• 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^[1] (See epidemiology below)

• Heredity
• Smoking
• Drug use, such as cocaine.^{[citation needed]}

• Stress
• Diaphragm weakness ^[2]

Diagnosis

Upper GI endoscopy depicting hiatus hernia.

The diagnosis of a hiatus hernia is typically made through an upper GI series or endoscopy.

Types

There are two major kinds of hiatus hernia: ^[3]

• The most common (95%) is the sliding hiatus hernia, where the gastroesophageal junction moves above the diaphragm together with some of the stomach.
• The second kind is rolling (or paraesophageal) hiatus hernia, when a part of the stomach herniates through the esophageal hiatus and lies beside the esophagus, without movement of the gastroesophageal junction. It is about 20 times less common than the first kind. ^[4]

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

Treatment

In most cases, sufferers experience no discomfort and no treatment is required. However, 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.

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.

The surgical procedure used is called 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.^[5]

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

A hiatus hernia per se does not cause any symptoms. The condition promotes reflux of gastric contents (via its direct and indirect actions on the anti-reflux mechanism) and thus is associated with gastroesophageal reflux disease (GERD). In this way a hiatus hernia is associated with all the potential consequences of GERD - heartburn, esophagitis, Barrett's esophagus and esophageal cancer. However the risk attributable to the hiatus hernia is difficult to quantify, and at most is low.

Besides discomfort from GERD and dysphagia, hiatal hernias can have severe consequences for patients if not treated. While sliding hernias are primarily associated with gastroesophageal acid reflux, rolling hernias can strangulate a portion of the stomach above the diaphragm. This strangulation can result in esophageal or GI tract obstruction and the tissue even become ischemic and necrose.

Another severe complication, although very rare, is a large herniation that can restrict the inflation of a lung, causing pain and breathing problems.

Epidemiology

Hiatus hernias affect anywhere from 1 to 20% of the population.^{[citation needed]} Of these, 9% are symptomatic, depending on the competence of the lower esophageal sphincter (LES). 95% of these are "sliding" hiatus hernias, in which the LES protrudes above the diaphragm along with the stomach, and only 5% are the "rolling" type (paraesophageal), in which the LES remains stationary but the stomach protrudes above the diaphragm. People of all ages can get this condition, but it is more common in older people.

According to Dr. Denis Burkitt, "Hiatus hernia has its maximum prevalence in economically developed communities in North America and Western Europe....In contrast the disease is rare in situations typified by rural African communities."^[1] Burkitt attributes the disease to insufficient dietary fiber and the use of the unnatural sitting position for defecation. Both factors create the need for straining at stool, increasing intraabdominal pressure and pushing the stomach through the esophageal hiatus in the diaphragm.

Notes and references

1. ^ ^{a b} Burkitt DP (1981). "Hiatus hernia: is it preventable?". Am. J. Clin. Nutr. 34 (3): 428–31. PMID 6259926. http://www.ajcn.org/cgi/reprint/34/3/428.pdf. 
2. ^ | url=http://en.wikipedia.org/wiki/Thoracic_diaphragm#Pathology
3. ^ 01011 at CHORUS
4. ^ Lawrence, P. (1992). Essentials of General Surgery. Baltimore: Williams & Wilkins. p. 178. ISBN 0-683-04869-4. 
5. ^ Lange CMDT 2006

External links

Wikimedia Commons has media related to: Hiatal hernia

• 01011 at CHORUS

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