Hiatus hernia overview
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
A hiatus hernia is the protrusion (or herniation) of the upper part of the stomach into the thorax through a tear or weakness in the diaphragm.
Historical Perspective
Classification
Hiatus hernia may be classified into four subtypes: Type I: Sliding hernia and Type II, III, IV: Paraesophageal hernias(rolling hernias)
Pathophysiology
Causes
The cause of hiatus hernia has not been identified clearly. Hiatus hernia is due to herniation of contents of the abdominal cavity through the esophageal hiatus of the diaphragm due to weakning of the muscles around esophagus .Hiatus hernia may be caused by older age,trauma,congenital defects,increase in the abdominal pressure,obesity and smoking.
Differentiating Hereditary pancreatitis from Other Diseases
Hiatus hernia presents as gastroesophageal reflux disease(GERD) with dysphagia and must be differentiated from other causes of dysphagia
Epidemiology and Demographics
Hiatus hernias affect anywhere from 1 to 20% of the population. 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.
Risk Factors
Common risk factors in the development of hiatus hernia include aging, obesity, trauma, scoliosis and congenital defects..
Natural History, Complications, and Prognosis
The symptoms of a hiatus hernia usually develop in the first decade of life in children and start with symptoms such as vomiting, heartburn, regurgitation, and dysphagia. If left untreated, patients with a hiatus hernia may progress to develop strangulation, esophageal adenocarcinoma, and gastric volvulus. Prognosis is generally excellent and recovery after surgery in a large hernia is approximately 90%. The disease is well controlled with medical therapy but not cured.
Diagnosis
History and 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.
Physical Examination
Chest X Ray
On chest radiographs, a paraesophageal hernia may appear as a soft-tissue-opacity lesion posterior to the heart near the esophageal hiatus.
CT
CT helps verify migration of the stomach cranially through the hiatus. Sagittal and coronal reformatted images often help demonstrate the hernia and the hiatal defect.
Other Imaging Findings
A hiatal hernia occurs when a part of the stomach protrudes into the thoracic cavity through the esophageal hiatus of the diaphragm. Approximately 99% of hiatal hernias are sliding, and the rest 1% are paraesophageal hernia. Barium swallow may be helpful in the diagnosis of a hiatus hernia. Findings on a Barium swallow suggestive hiatus hernia include anatomy and size of a hernia, the orientation of the stomach location of the gastroesophageal junction.
Other Diagnostic Studies
There are no other diagnostic studies associated with a hiatus hernia.
Treatment
Medical Therapy
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 lower 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.
Surgery
Surgery is the mainstay of treatment for patients with a symptoms or complications. Paraesophageal hernias can be repaired transabdominally or transthoracically. Laparoscopic approach is preferred for most patients. A Nissen-fundoplication is usually done with the surgery. Overall mortality and morbidity rates associated with laparoscopic paraesophageal hernia repair are low. A fixation of the stomach to the abdominal wall (anterior gastropexy) can be used to reduce the risk of gastric reherniation into the thoracic cavity. Complications include pneumonia, pulmonary embolism, heart failure, postoperative leak, and recurrence.
Primary Prevention
There are no established measures for the primary prevention of hiatus hernia.
Secondary Prevention
There are no established measures for the secondary prevention of hiatus hernia.