Hiatus hernia

Hiatus hernia
Classification and external resources
Specialty Gastroenterology, general surgery
ICD-10 K44, Q40.1
ICD-9-CM 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 the esophageal hiatus because of a tear or weakness in the diaphragm. Hiatus hernias often result in heartburn but may also cause chest pain or pain with eating.[1]

The most common cause is obesity. The diagnosis is often by endoscopy or medical imaging.[1]

A hiatus hernia may be treated with lifestyle changes such as raising the head of the bed, weight loss, and adjusting eating habits. Medications such as H2 blockers or proton pump inhibitors may help. If the symptoms do not improve with medications the surgery known as laparoscopic fundoplication may be an option.[1] It is not known how commonly hiatus hernias occur with estimates in North America varying from 10 to 80%.[1]

Signs and symptoms

Hiatal hernia.

Hiatal hernia has often been called the "great mimic" because its symptoms can resemble many disorders. For example, a person with this problem can experience dull pains in the chest, shortness of breath (caused by the hernia's effect on the diaphragm), heart palpitations (due to irritation of the vagus nerve), and swallowed food "balling up" and causing discomfort in lower esophagus until it passes on to stomach.

In most cases however, a hiatal hernia does not cause any symptoms. The pain and discomfort that a patient experiences is due to the reflux of gastric acid, air, or bile. While there are several causes of acid reflux, it does happen more frequently in the presence of hiatal hernia.

For newborn the presence of Bochdalek hernia can be recognised[2] from symptoms such as difficulty breathing[3] fast respiration, increased heart rate.[4]

Risk factors

The following are risk factors that can result in a hiatus hernia.

Diagnosis

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

Classification

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, and D is a paraesophageal (rolling) type.

Four types of esophageal hiatal hernia are identified:[5]

Type I: With type I there is a widening of the muscular hiatal tunnel and circumferential laxity of the phrenoesophageal membrane, allowing a portion of the gastric cardia to herniate upward into the posterior mediastinum. The clinical significance of type I hernias is in their association with reflux disease. They are the most common type, accounting for 95-85% of all hiatal hernias. (C)

Type II: A type II hernia results from a localized defect in the phrenoesophageal membrane while the gastroesophageal junction remains fixed to the pre aortic fascia and the median arcuate ligament. The gastric fundus then serves as the leading point of herniation. Although type II hernias are associated with reflux disease, their primary clinical significance lies in the potential for mechanical complications. (D)

Type III: Type III hernias have elements of both types I and II hernias. With progressive enlargement of the hernia through the hiatus, the phrenoesophageal membrane stretches, displacing the gastroesophageal junction above the diaphragm, thereby adding a sliding element to the type II hernia.

Type IV: Type IV hiatus hernia is associated with a large defect in the phrenoesophageal membrane, allowing other organs, such as colon, spleen, pancreas and small intestine to enter the hernia sac.

The end stage of type I and type II hernias occurs when the whole stomach migrates up into the chest by rotating 180° around its longitudinal axis, with the cardia and pylorus as fixed points. In this situation the abnormality is usually referred to as an intrathoracic stomach.

Treatment

In most cases, sufferers experience no discomfort and no treatment is required. If there is pain or discomfort, 3 or 4 sips of room temperature water will usually relieve the pain. 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. 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 (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 recent studies have indicated low complication rates, quick recovery, and relatively good long term results.[6][7][8][9][10]

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.

Epidemiology

Incidence of hiatal hernias increases with age; approximately 60% of individuals aged 50 or older have a hiatal hernia.[11] 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."[12] 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.[13]

References

  1. 1 2 3 4 Roman, S; Kahrilas, PJ (23 October 2014). "The diagnosis and management of hiatus hernia.". BMJ (Clinical research ed.) 349: g6154. doi:10.1136/bmj.g6154. PMID 25341679.
  2. ↑ doi: 10.1016/s1875-9572(10)60006-x
  3. ↑ doi: :10.1016/j.athoracsur.2013
  4. ↑ doi:10.1016/s0377-1237(05)80177-7
  5. ↑ Kahrilas, Peter J.; Kim, Hyon C.; Pandolfino, John E. "Approaches to the diagnosis and grading of hiatal hernia". Best Practice & Research Clinical Gastroenterology 22 (4): 601–616. doi:10.1016/j.bpg.2007.12.007. PMC 2548324. PMID 18656819.
  6. ↑ Migaczewski M, et al. (January 2013). "Laparoscopic Nissen fundoplication in the treatment of Barrett's esophagus". NCBI 8 (PMC3699774): 139–45. doi:10.5114/wiitm.2011.32941. PMC 3699774. PMID 23837098.
  7. ↑ Testoni PA, et al. (May 2012). "Transoral incisionless fundoplication for treatment of gastroesophageal reflux disease in clinical practice". NCBI 26 (PMC3472060): 3307–15. doi:10.1007/s00464-012-2324-2. PMC 3472060. PMID 22648098.
  8. ↑ Ozmen V, et al. (Dec 2005). "Histologic and clinical outcome after laparoscopic Nissen fundoplication for gastroesophageal reflux disease and Barrett's esophagus". NCBI 20: 226–9. doi:10.1007/s00464-005-0434-9. PMID 16362470.
  9. ↑ Abbas AE, et al. (Feb 2004). "Barrett's esophagus: the role of laparoscopic fundoplication". NCBI 77: 393–6. doi:10.1016/S0003-4975(03)01352-3. PMID 14759403.
  10. ↑ "Journal Index PDF (fee for article)" (PDF). Lange Current Medical Diagnosis & Treatment 2006.
  11. ↑ Goyal Raj K, "Chapter 286. Diseases of the Esophagus". Harrison's Principles of Internal Medicine, 17e.
  12. ↑ Burkitt DP (1981). "Hiatus hernia: is it preventable?" (PDF). Am. J. Clin. Nutr. 34 (3): 428–31. PMID 6259926.
  13. ↑ Sontag S (1999). "Defining GERD". Yale J Biol Med 72 (2-3): 69–80. PMC 2579007. PMID 10780568.

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