Hiatal Hernia - Symptoms, Types, Causes, Treatment and Prevention
A hiatal hernia is a medical disorder where the diaphragm opens, and the upper portion of the stomach or other internal organ protrudes. The muscular structure that helps in breathing, called the diaphragm, has a tiny opening (hiatus). The esophagus travels through this small opening in the diaphragm, and this is called the gastroesophageal junction (GEJ). The lower esophageal sphincter (LES) is compromised when the stomach pushes through that opening and into the chest, resulting in a hiatal hernia. The main cause of gastroesophageal reflux disease (GERD) is the laxity of the lower esophageal sphincter (LES), which can allow stomach contents and acid to reflux back up into the esophagus. Although most hiatal hernias are asymptomatic and treatable with medications, large hiatal hernias might require surgery.
Hiatal hernia Definition
A hiatal hernia is a sac formed by the peritoneum, the lining of the abdominal cavity. A hiatus hernia occurs when a portion of the stomach pushes through the diaphragm's (A broad, thin layer of muscle that lies between the chest and the abdomen) opening and into the chest.
Hernia Meaning
Hernia means ‘to bud’ or ‘to protrude’ in Greek. It is also called ‘rupture’ in Latin. Hiatus is a mid-16th century word meaning ‘a physical gap’ or ‘hiare gape’ in Latin.
Hiatal hernia types
The hiatal hernias are classified into four types as mentioned below:
- Type I- Sliding type
- Type II- Paraesophageal hiatal hernia
- Type III- Both paraesophageal and sliding hernia
- Type IV- When the stomach, colon, small intestine, or spleen herniate into the chest.
Type I- Sliding hiatal hernia
- This sliding type of hernias constitutes more than 95% of total hiatal hernias and occurs when the gastroesophageal junction (GEJ) is displaced upwards in the direction of the hiatus.
- The medical significance of the sliding type of hernias is associated with reflux disease.
Type II- Paraesophageal hiatal hernia
- When a portion of the stomach slides into the mediastinum parallel to the esophagus, it can cause a paraesophageal hernia.
- A paraesophageal or rolling hernia, sometimes referred to as a type II hernia, is a condition in which the stomach's fundus and larger curvature roll up through the diaphragm to form a sac next to the esophagus. The gastroesophageal junction is still connected to the pre-aortic fascia and the median arcuate ligament, however there is a localized defect in the phrenoesophageal ligament. The leading point of the herniation is subsequently the gastric fundus. Type II hernias are linked to reflux illness, although the possibility of mechanical consequences is primarily important from a medical perspective.
Type III- Both paraesophageal and sliding hernia
- Type III hernias are a blend of both type I and type II hernias. The phrenoesophageal ligament extends as the hernia enlarges across the hiatus, pushing the gastroesophageal junction above the diaphragm and adding a sliding component to the type II hernia.
Type IV hiatal hernia
- A significant phrenoesophageal ligament deficiency linked to type IV hiatus hernia permits the pancreas, spleen, small intestine or colon to pass into the hernia sac.
- When the cardia and pylorus act as fixed points and the entire stomach migrates up into the chest by rotating 180° along its longitudinal axis, type I and type II hernias reach their final stage. The anomaly in this case is typically called an intrathoracic stomach.
Hiatal
hernia prevalence
- As people age, hiatal hernias become more common. Between 55 to 60 percent of people over 50 years of age suffer from a hiatal hernia. Nevertheless, depending on the nature and function of the lower esophageal sphincter, only approximately 9% have symptoms.
- Type I sliding hiatal hernias account for the great majority of these hernias. Just 5% of hiatal hernias are type II paraesophageal hernias, in which the stomach protrudes above the diaphragm while the lower esophageal sphincter (LES) stays in place.
- Additionally, there is a higher frequency in females, which may be related to elevated intra-abdominal pressure during pregnancy.
Hiatal hernia causes
- Hiatal hernias can develop over time or be congenital. It is thought that age-related muscle weakness and a decrease in suppleness and flexibility predisposes people to developing a hiatal hernia. This could prevent the top portion of the stomach from swallowing and returning to its normal position beneath the diaphragm.
- There are other known risk factors, such as high intra-abdominal pressure. Obesity, pregnancy, chronic constipation, and chronic obstructive pulmonary disease (COPD) are the usual causes of this. Age, trauma, prior surgeries, genetics, and other factors might potentially contribute to the development of a hiatal hernia. Some of the major causes of hiatal hernias includes:
- Having an abnormally large hiatus at birth
- Trauma or injury to the region, such as force from a seatbelt in an accident
- Obesity
- Chronic and severe pressure on the surrounding muscles brought on by:
- Persistent cough
- Lifting heavy weights
- Vomiting
- Straining to pass bowel
Hiatal hernia symptoms
Acidic reflux is not commonly seen in every hiatal hernia patient, and not every patient with acidic reflux gets hiatal hernia. But if a patient notices these symptoms more frequently, they might be related. These include:
- Heartburn: Patient may feel a burning sensation in the chest, mostly after having food.
- Noncardiac chest pain: Angina-like recurrent chest pain is one of the symptoms.
- Indigestion: Heartburn-like symptoms with burning and abdominal pain. A Feeling of fullness after eating food is also observed in a few patients
- Burping and regurgitation: Reflux of acid, food, or gas into throat can be seen in some patients
- Dysphagia: Feeling difficulty in swallowing food or a lump in the throat
- Sore throat: Irritation due to acid, causes sore throat and hoarseness while speaking.
- Nausea: due to compression of your stomach or acid overflow, or both.
- Shortness of breath: if the hernia is compressing the lungs, one might feel shortness of breath.
Hiatal hernia diagnosis
A medical professional may employ several diagnostic methods to find a hiatal hernia, but they will start with a physical examination and medical history before performing the below mentioned diagnostic tests:
- Endoscopy: When evaluating patients with a possible hiatal hernia and gastroesophageal reflux disease who are being considered for surgery, endoscopy remains to be a crucial procedure. This investigation can confirm the existence of esophageal damage and rule out other conditions like malignancies.
- Manometry: The purpose of this investigation is to rule out primary motility problems, like achalasia, which can resemble reflux symptoms. Rather than a Nissen, patients with primary motility issues may need a partial fundoplication.
- pH monitoring: The most effective method for identifying acid reflux is the 24-hour pH test. The amount of acid that is exposed to a probe that is positioned 5 cm above the gastroesophageal junction is measured in this investigation.
- Esophagography: The esophagogram reveals substantial data on the anatomy of proximal stomach and esophagus. During this investigation, anatomic anomalies like tumors or strictures could also be found
- Barium X-ray: Barium X-ray or computed tomography scan of the upper gastrointestinal tract to find the positioning of the gastric organs
Hiatal hernia treatment
The treatment modalities of hiatal hernia include different approaches based on the type of hernia and the severity of symptoms as specified below:
- Medications
- Surgical therapy
- Diet based approach
- Lifestyle modifications
Hiatal hernia medication
Initially, proton pump inhibitors will be given to patients presenting clinical signs of gastroesophageal reflux disease. Prescribing these proton pump inhibitors acts as diagnostic evaluation as well and helps in deciding the treatment regimen for hernia in patients. Medications that a doctor may prescribe include:
- Over the counter (OTC) antacid drugs to alkalize stomach acid
- Counter available drugs or Hydrogen(H2) receptor blockers to cut down the production of acid in the stomach.
- Over the counter medicines or proton pump inhibitors which prevent acid production and allows the esophagus to heal
Surgical treatment for hiatal hernia
When a hiatal hernia is repaired surgically, the stomach and any surrounding tissue are typically pushed down from the chest cavity and back into the abdomen through tiny incisions. To treat reflux, the surgeon may also repair an esophageal valve and reduce the size of the diaphragm opening. Some of the surgical procedures to treat hiatal hernia are as mentioned below:
- Nissen fundoplication (360-degree wrap): In this procedure, the surgical gastroenterologist / surgeon completely wraps the gastroesophageal junction with the fundus of the stomach. Upon wrapping, the entire wrap is attached to the hiatus and esophagus by removing the 52 french bougie. This helps in preventing slippage or herniation.
- Partial fundoplication: Partial fundoplication is the procedure of choice in case of poor esophageal motility. This procedure is commonly done in two ways.
- Dor procedure: The anterior aspect of the esophagus is covered by the fundus and attaches it to the esophagus and hiatus like performed in nissen fundoplication. This is the preferred method to treat achalasia patients with anterior myotomy rather than in patients with gastric esophageal reflux disease.
- Toupet procedure: This involves almost the same procedure as nissen involving entire esophageal dissection. But, unlike in Nissen procedure, this surgery wraps.
Hiatal hernia diet
Changing the diet could reduce the acid reflux symptoms caused by hiatal hernia. An efficient diet plan may help to consume food in smaller quantities more often instead of large meals less frequency. One should avoid having snacks just before going to bed. Given below are some of the foods to avoid that could increase the risk of heartburn:
- Processed foods
- Spicy foods
- Chocolate
- Caffeinated drinks
- Onions
- Citrus fruits
Lifestyle modifications
Practicing lifestyle modifications like below would help in alleviating the symptoms:
- Smoking cessation
- Raising the height of the pillow by at least 6 inches
- Not to lie down immediately after having food
Hiatal hernia complications
Complications from surgery are typically minor and not directly related to the surgery itself. It is estimated that the overall 30-day mortality rate associated with antireflux surgery is 0.19%. Antireflux surgery related complications include the following:
- Pneumothorax: This is the most common intraoperative complication. However, this is reported to occur in less than 2% of patients.
- Splenic and liver injuries: This can result in bleeding and occurs in about 2.3% of patients. Major injury is rare.
- Dysphasia: This typically resolves without further intervention and is most commonly caused by postoperative edema.
Prevention of hiatal hernias
Even doctors are uncertain about hiatal hernia causes and prevention. However, a few factors like obesity and tobacco smoking might increase the risk of a hiatal hernia. Hence, it is suggested to maintain a moderate weight and quit smoking.
Frequently Asked Questions (FAQs) on Hiatal hernia
-
What is the connection between GERD and hiatal hernias?
When food, drinks, and stomach acid escape into your esophagus, it is known as gastroesophageal reflux disease, or GERD. After eating, this could cause nausea or heartburn. GERD is frequently experienced by individuals who have a hiatal hernia, but that does not imply that one circumstance causes the other, though. It is possible to have GERD without a hiatal hernia or the other way around.
-
How long does a hiatus hernia last?
If you don't obtain treatment for a hiatus hernia that is severe or getting worse, it might cause major problems and last longer than three weeks. Long-term gullet inflammation, a higher risk of oesophageal cancer, and a medical emergency due to strangulated hernia are among the complications.
-
Can a hiatal hernia reduce itself?
Hiatal hernias do not heal on their own. Surgery is the only method to reposition the upper portion of your stomach behind your diaphragm. But by practicing hiatal hernia self-care and adopting certain dietary and lifestyle modifications, you can reduce symptoms: Consume meals more frequently and in smaller portions.
-
Does walking affect hiatal hernia?
For those who have hiatal hernias, gentle, low-impact exercises that don't put undue strain on the stomach are usually the best. Walking, running, yoga, and swimming are a few examples. Nonetheless, some yoga positions may make GERD symptoms worse.
What is a hiatal hernia?
Acid reflux and other conditions that can easily back up (reflux or spew) into the esophagus are retained when the upper portion of the stomach pushes up into the chest through a little gap in the diaphragm. This condition is known as a hiatal hernia.
Are the surgical procedures minimally invasive?
When the surgical method is applied as the initial procedure to treat hiatal hernias, it is most effective. On the other hand, re-operations are more involved. To get the greatest outcomes, each patient and their previous operation must be carefully evaluated. If a previous laparoscopic procedure has failed, then in certain cases a more conventional open operation is the best course of action.
What is robotic surgery, and is it better than minimally invasive surgery to treat hiatal hernias?
In robotic surgery, a surgeon utilizes laparoscopic instruments guided by a robotic arm or arms to perform a planned surgical treatment while seated at a console away from the patient. This type of surgery is considered less invasive. Numerous scientific research conducted so far have not demonstrated any benefit of robotic surgery over minimally invasive or laparoscopic surgery for hiatal hernias.
Is mesh used in hiatal hernia surgery?
The majority of hiatal hernias may be fixed using a patient’s own natural diaphragm muscle. To enhance the surgical repair, a surgical mesh (made of synthetic materials) might be required if the diaphragm's muscles are extremely weak.
What is the best position to sleep with a hiatal hernia?
Place 6 to 8-inch-tall blocks behind the bedposts to raise the head of your bed. As you sleep, this keeps stomach secretions in the fundus of the stomach. For the same reason, sleep on your left side. Avoid wearing tight belts or anything that clings to the abdomen.
What are the hiatal hernia disease symptoms?
Burping, nausea, vomiting, acid reflux, heart burn, regurgitation are a few symptoms of hiatal hernia disease.
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