Hiatus hernia

Hiatus hernia
Synonyms Hiatal hernia
A drawing of a hiatus hernia
Specialty Gastroenterology, general surgery
Symptoms Taste of acid in the back of the mouth, heartburn, trouble swallowing[1]
Complications Iron deficiency anemia, volvulus, bowel obstruction[1]
Types Sliding, paraesophageal[1]
Risk factors Obesity, older age, major trauma[1]
Diagnostic method Endoscopy, medical imaging, manometry[1]
Treatment Raising the head of the bed, weight loss, medications, surgery[1]
Medication H2 blockers, proton pump inhibitors[1]
Frequency 10–80% (US)[1]

A hiatus hernia is a type of hernia in which abdominal organs (typically the stomach) slip through the diaphragm into the middle compartment of the chest.[2][1] This may result in gastroesophageal reflux disease (GERD) with symptoms such as a taste of acid in the back of the mouth or heartburn.[2][1] Other symptoms may include trouble swallowing and chest pains.[1] Complications may include iron deficiency anemia, volvulus, or bowel obstruction.[1]

The most common risk factors are obesity and older age.[1] Other risk factors include major trauma, scoliosis, and certain types of surgery.[1] There are two main types, a sliding hernia in which the body of the stomach moves up and a paraesophageal hernia in which an abdominal organ moves beside the esophagus.[1] The diagnosis may be confirmed with endoscopy or medical imaging.[1] Endoscopy is typically only required when concerning symptoms are present, symptoms are resistant to treatment, or the person is over 50 years of age.[1]

Symptoms from a hiatus hernia may be improved by changes such as raising the head of the bed, weight loss, and adjusting eating habits.[1] Medications that reduce gastric acid such as H2 blockers or proton pump inhibitors may also help with the symptoms.[1] If the condition does not improve with medications, a surgery to carry out a laparoscopic fundoplication may be an option.[1] Between 10% and 80% of people in the United States are affected.[1]

Signs and symptoms

Hiatal hernia has often been called the "great mimic" because its symptoms can resemble many disorders. Among them, a person with a hiatal hernia 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 addition, hiatal hernias often result in heartburn but may also cause chest pain or pain with eating.[1]

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 occurs more frequently in the presence of hiatal hernia.

In newborns, the presence of Bochdalek hernia can be recognised[3] from symptoms such as difficulty breathing[4] fast respiration, increased heart rate.[5]

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:[7]

Type I: A type I hernia is also known as a sliding hiatal hernia. 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. Sliding hernias are the most common type, and account for 95% of all hiatal hernias.[8] (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 the great majority of cases, sufferers experience no life-altering 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. 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. Antisecretory drugs like proton pump inhibitors and H2 receptor blockers can be used to reduce acid secretion. Medications that reduce the lower esophageal sphincter (LES) pressure should be avoided.

However, in some unusual instances, as when the hiatal hernia is unusually large, or is of the paraesophageal type, it may cause esophageal stricture or severe discomfort. About 5% of hiatus hernias are paraesophageal. If symptoms from such a hernia are severe for example if chronic acid reflux threatens to severely injure the esophagus or is causing Barrett's esophagus, surgery is sometimes recommended. However surgery has its own risks including death and disability, so that even for large or paraesophageal hernias, watchful waiting may on balance be safer and cause fewer problems than surgery.[9] Complications from surgical procedures to correct a hiatus hernia may include gas bloat syndrome, dysphagia (trouble swallowing), dumping syndrome, excessive scarring, and rarely, achalasia.[9] Surgical procedures sometimes fail over time, requiring a second surgery to make repairs.

One 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 relatively low complication rates, quick recovery, and relatively good long term results.[10][11][12][13][14]

Epidemiology

Incidence of hiatal hernias increases with age; approximately 60% of individuals aged 50 or older have a hiatal hernia.[15] 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.

Hiatus hernia are most common in North America and Western Europe and rare in rural African communities.[16] Some have proposed that insufficient dietary fiber and the use of a high sitting position for defecation may increase the risk.[17]

References

  1. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 Roman, S; Kahrilas, PJ (23 October 2014). "The diagnosis and management of hiatus hernia.". BMJ (Clinical research ed.). 349: g6154. PMID 25341679. doi:10.1136/bmj.g6154.
  2. 1 2 "Hiatal Hernia". PubMed Health. Retrieved 6 May 2017.
  3. ↑ Chang SW, Lee HC, Yeung CY, Chan WT, Hsu CH, Kao HA, Hung HY, Chang JH, Sheu JC, Wang NL (2010). "A twenty-year review of early and late-presenting congenital Bochdalek diaphragmatic hernia: are they different clinical spectra?". Pediatr Neonatol. 51 (1): 26–30. PMID 20225535. doi:10.1016/S1875-9572(10)60006-X.
  4. ↑ Ganeshan DM, Correa AM, Bhosale P, Vaporciyan AA, Rice D, Mehran RJ, Walsh GL, Iyer R, Roth JA, Swisher SG, Hofstetter WL. "Diaphragmatic hernia after esophagectomy in 440 patients with long-term follow-up". Ann Thorac Surg. 96: 1138–45. PMID 23810174. doi:10.1016/j.athoracsur.2013.04.076.
  5. ↑ Alam, A; Chander, B.N. (July 2005). "Adult bochdalek hernia". MJAFI. 61 (3): 284–6. doi:10.1016/S0377-1237(05)80177-7.
  6. 1 2 "UOTW #39 - Ultrasound of the Week". Ultrasound of the Week. 25 February 2015. Retrieved 27 May 2017.
  7. ↑ 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. PMC 2548324 Freely accessible. PMID 18656819. doi:10.1016/j.bpg.2007.12.007.
  8. ↑ Dennis Kasper; Anthony Fauci; Stephen Hauser; Dan Longo; J. Larry Jameson; Joseph Loscalzo. Harrison's Principles of Internal Medicine, 19e (19 ed.). McGraw-Hill Global Education. p. 1902. ISBN 978-0071802154.
  9. 1 2 Stylopoulos N, Gazelle GS, Rattner DW. "Paraesophageal hernias: operation or observation?". Ann Surg. 236: 492–500. PMC 1422604 Freely accessible. PMID 12368678. doi:10.1097/01.SLA.0000029000.06861.17.
  10. ↑ Migaczewski M, Pędziwiatr M, Matłok M, Budzyński A (2013). "Laparoscopic Nissen fundoplication in the treatment of Barrett's esophagus — 10 years of experience". Wideochir Inne Tech Maloinwazyjne. 8 (2): 139–45. PMC 3699774 Freely accessible. PMID 23837098. doi:10.5114/wiitm.2011.32941.
  11. ↑ Witteman BP, Strijkers R, de Vries E, Toemen L, Conchillo JM, Hameeteman W, Dagnelie PC, Koek GH, Bouvy ND (2012). "Transoral incisionless fundoplication for treatment of gastroesophageal reflux disease in clinical practice". Surg Endosc. 26 (11): 3307–15. PMC 3472060 Freely accessible. PMID 22648098. doi:10.1007/s00464-012-2324-2.
  12. ↑ Ozmen V, Oran ES, Gorgun E, Asoglu O, Igci A, Kecer M, Dizdaroglu F (2006). "Histologic and clinical outcome after laparoscopic Nissen fundoplication for gastroesophageal reflux disease and Barrett's esophagus". Surg Endosc. 20 (2): 226–9. PMID 16362470. doi:10.1007/s00464-005-0434-9.
  13. ↑ Abbas AE, Deschamps C, Cassivi SD, Allen MS, Nichols FC, Miller DL, Pairolero PC (2004). "Barrett's esophagus: the role of laparoscopic fundoplication". Ann. Thorac. Surg. 77 (2): 393–6. PMID 14759403. doi:10.1016/S0003-4975(03)01352-3.
  14. ↑ "Journal Index PDF (fee for article)" (PDF). Lange Current Medical Diagnosis & Treatment 2006.
  15. ↑ Goyal Raj K, "Chapter 286. Diseases of the Esophagus". Harrison's Principles of Internal Medicine, 17e.
  16. ↑ Burkitt DP (1981). "Hiatus hernia: is it preventable?" (PDF). Am. J. Clin. Nutr. 34 (3): 428–31. PMID 6259926.
  17. ↑ Sontag S (1999). "Defining GERD". Yale J Biol Med. 72 (2-3): 69–80. PMC 2579007 Freely accessible. PMID 10780568.
Classification
V · T · D
External resources


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