Hiatus hernia
Encyclopedia
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.
A third kind is also sometimes described, and is a combination of the first and second kinds.
), and heart palpitations (due to irritation of the vagus nerve
).
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.
The diagnosis of a hiatus hernia is typically made through an upper GI series
, endoscopy or high resolution manometry
.
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.
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.
(GERD). In this way a hiatus hernia is associated with all the potential consequences of GERD – heartburn
, esophagitis
, Barrett's esophagus
, esophageal cancer
and dental erosion. 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 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 can 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.
Most cases are asymptomatic.
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." 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.
Stomach
The stomach is a muscular, hollow, dilated part of the alimentary canal which functions as an important organ of the digestive tract in some animals, including vertebrates, echinoderms, insects , and molluscs. It is involved in the second phase of digestion, following mastication .The stomach is...
into the thorax
Chest
The chest is a part of the anatomy of humans and various other animals. It is sometimes referred to as the thorax or the bosom.-Chest anatomy - Humans and other hominids:...
through a tear or weakness in the diaphragm.
Classification
There are two major kinds of hiatus hernia:- 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 hiatusEsophageal hiatusIn human anatomy, the esophageal hiatus is a hole in the diaphragm through which the esophagus passes. It is located in the right crus of the diaphragm.It is located approximately at level of the tenth thoracic vertebra ....
and lies beside the esophagus, without movement of the gastroesophageal junction. It accounts for the remaining 5% of hiatus hernias.
A third kind is also sometimes described, and is a combination of the first and second kinds.
Signs and symptoms
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 diaphragmDiaphragm
-Optics and photography:* Diaphragm , a stop in the light path of a lens, having an aperture that regulates the amount of light that passes* Diaphragm shutter, a type of leaf shutter consisting of a number of thin blades in a camera-Acoustics:...
), and heart palpitations (due to irritation of the vagus nerve
Vagus nerve
The vagus nerve , also called pneumogastric nerve or cranial nerve X, is the tenth of twelve paired cranial nerves...
).
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.
Risk factors
The following are risk factors that can result in a hiatus hernia.- Increased pressure within the abdomenAbdomenIn vertebrates such as mammals the abdomen constitutes the part of the body between the thorax and pelvis. The region enclosed by the abdomen is termed the abdominal cavity...
caused by:- Heavy lifting or bending over
- Frequent or hard coughing
- Hard sneezing
- PregnancyPregnancyPregnancy refers to the fertilization and development of one or more offspring, known as a fetus or embryo, in a woman's uterus. In a pregnancy, there can be multiple gestations, as in the case of twins or triplets...
and delivery - Violent vomitingVomitingVomiting is the forceful expulsion of the contents of one's stomach through the mouth and sometimes the nose...
- Straining with constipationConstipationConstipation refers to bowel movements that are infrequent or hard to pass. Constipation is a common cause of painful defecation...
- ObesityObesityObesity is a medical condition in which excess body fat has accumulated to the extent that it may have an adverse effect on health, leading to reduced life expectancy and/or increased health problems...
(extra weight pushes down on the abdomen increasing the pressure) - Use of the sitting position for defecationDefecationDefecation is the final act of digestion by which organisms eliminate solid, semisolid or liquid waste material from the digestive tract via the anus. Waves of muscular contraction known as peristalsis in the walls of the colon move fecal matter through the digestive tract towards the rectum...
(See epidemiology below)
- HeredityHeredityHeredity is the passing of traits to offspring . This is the process by which an offspring cell or organism acquires or becomes predisposed to the characteristics of its parent cell or organism. Through heredity, variations exhibited by individuals can accumulate and cause some species to evolve...
- SmokingTobacco smokingTobacco smoking is the practice where tobacco is burned and the resulting smoke is inhaled. The practice may have begun as early as 5000–3000 BCE. Tobacco was introduced to Eurasia in the late 16th century where it followed common trade routes...
- Drug useRecreational drug useRecreational drug use is the use of a drug, usually psychoactive, with the intention of creating or enhancing recreational experience. Such use is controversial, however, often being considered to be also drug abuse, and it is often illegal...
, such as cocaine - StressStress (medicine)Stress is a term in psychology and biology, borrowed from physics and engineering and first used in the biological context in the 1930s, which has in more recent decades become commonly used in popular parlance...
- Diaphragm weakness
Diagnosis
Upper GI series
Upper GI series, also upper gastrointestinal tract radiography, is a radiologic examination of the upper gastrointestinal tract. It consists of a series of X-ray images of the esophagus, stomach and duodenum...
, endoscopy or high resolution manometry
High resolution manometry
High-resolution manometry is a gastrointestinal motility diagnostic system that measures intraluminal pressure activity within the gastrointestinal tract using a series of closely spaced pressure sensor. For a manometry system to be classified as "high resolution" as opposed to "conventional",...
.
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 strictureEsophageal stricture
Benign esophageal stricture is a narrowing or tightening of the esophagus that causes swallowing difficulties.-Causes:It can be caused by or associated with gastroesophageal reflux disease, esophagitis , dysfunctional lower esophageal sphincter, disordered motility, lye ingestion, or a hiatal hernia...
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
Stress management
Stress management is the alteration of stress and especially chronic stress often for the purpose of improving everyday functioning.Stress produces numerous symptoms which vary according to persons, situations, and severity. These can include physical health decline as well as depression. According...
may be prescribed, or if overweight, weight loss
Weight loss
Weight loss, in the context of medicine, health or physical fitness, is a reduction of the total body mass, due to a mean loss of fluid, body fat or adipose tissue and/or lean mass, namely bone mineral deposits, muscle, tendon and other connective tissue...
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
Surgery
Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...
is sometimes recommended, as chronic reflux can severely injure the esophagus
Esophagus
The esophagus is an organ in vertebrates which consists of a muscular tube through which food passes from the pharynx to the stomach. During swallowing, food passes from the mouth through the pharynx into the esophagus and travels via peristalsis to the stomach...
and even lead to esophageal cancer
Esophageal cancer
Esophageal cancer is malignancy of the esophagus. There are various subtypes, primarily squamous cell cancer and adenocarcinoma . Squamous cell cancer arises from the cells that line the upper part of the esophagus...
.
The surgical procedure used is called Nissen fundoplication
Nissen fundoplication
Nissen fundoplication is a surgical procedure to treat gastroesophageal reflux disease and hiatus hernia. In GERD it is usually performed when medical therapy has failed, but with paraesophageal hiatus hernia, it is the first-line procedure...
. 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
Gastric acid
Gastric acid is a digestive fluid, formed in the stomach. It has a pH of 1 to 2 and is composed of hydrochloric acid , and large quantities of potassium chloride and sodium chloride...
. The procedure is now commonly performed laparoscopically
Laparoscopic surgery
Laparoscopic surgery, also called minimally invasive surgery , bandaid surgery, or keyhole surgery, is a modern surgical technique in which operations in the abdomen are performed through small incisions as opposed to the larger incisions needed in laparotomy.Keyhole surgery makes use of images...
. With proper patient selection, laparoscopic fundoplication has low complication rates and a quick recovery.
Complications include gas bloat syndrome, dysphagia
Dysphagia
Dysphagia is the medical term for the symptom of difficulty in swallowing. Although classified under "symptoms and signs" in ICD-10, the term is sometimes used as a condition in its own right. Sufferers are sometimes unaware of their dysphagia....
(trouble swallowing), dumping syndrome
Gastric dumping syndrome
Gastric dumping syndrome, or rapid gastric emptying is a condition where ingested foods bypass the stomach too rapidly and enter the small intestine largely undigested. It happens when the upper end of the small intestine, the duodenum, expands too quickly due to the presence of hyperosmolar food...
, excessive scarring, and rarely, achalasia
Achalasia
Achalasia , also known as esophageal achalasia, achalasia cardiae, cardiospasm, and esophageal aperistalsis, is an esophageal motility disorder involving the smooth muscle layer of the esophagus and the lower esophageal sphincter...
. The procedure sometimes fails over time, requiring a second surgery to make repairs.
Prognosis
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 diseaseGastroesophageal reflux disease
Gastroesophageal reflux disease , gastro-oesophageal reflux disease , gastric reflux disease, or acid reflux disease is chronic symptoms or mucosal damage caused by stomach acid coming up from the stomach into the esophagus...
(GERD). In this way a hiatus hernia is associated with all the potential consequences of GERD – heartburn
Heartburn
Heartburn, also known as pyrosis or acid indigestion is a burning sensation in the chest, just behind the breastbone or in the epigastrium...
, esophagitis
Esophagitis
Esophagitis is inflammation of the esophagus. It may be acute or chronic. The acute esophagitis can be catarrhal or phlegmonous, whereas the chronic esophagitis may be hypertrophic or atrophic.-Infectious:...
, Barrett's esophagus
Barrett's esophagus
Barrett's esophagus refers to an abnormal change in the cells of the inferior portion of the esophagus. A positive diagnosis generally requires observing specific macroscopic and microscopic changes...
, esophageal cancer
Esophageal cancer
Esophageal cancer is malignancy of the esophagus. There are various subtypes, primarily squamous cell cancer and adenocarcinoma . Squamous cell cancer arises from the cells that line the upper part of the esophagus...
and dental erosion. 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 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 can even become ischemic and necrose
Necrosis
Necrosis is the premature death of cells in living tissue. Necrosis is caused by factors external to the cell or tissue, such as infection, toxins, or trauma. This is in contrast to apoptosis, which is a naturally occurring cause of cellular death...
.
Another severe complication, although very rare, is a large herniation that can restrict the inflation of a lung
Lung
The lung is the essential respiration organ in many air-breathing animals, including most tetrapods, a few fish and a few snails. In mammals and the more complex life forms, the two lungs are located near the backbone on either side of the heart...
, causing pain and breathing problems.
Most cases are asymptomatic.
Epidemiology
Incidence of hiatal hernias increases with age; approximately 60% of individuals aged 50 or older have a hiatal hernia. 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." 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.