The esophagus joins the mouth and throat to the stomach. It moves within the chest cavity and starts at the abdominal cavity through a hole in the diaphragm known as the esophageal hiatus. The term Hiatal hernia defines a condition where a portion of the stomach that ordinarily is located in the abdominal cavity swells or protrudes through the esophageal hiatus to sit within the chest cavity.
Normally, the place where the esophagus passes through the diaphragm is sealed by the phren oesophageal membrane, a thin membrane of tissue attaching the esophagus with the diaphragm where the esophagus crosses through the diaphragm so that the chest cavity and abdominal cavity are divided from each other. Since the esophagus shortens and lengthens with each swallow, essentially squeezing food into the stomach, this membrane requires elasticity to allow the esophagus to move up and down Normal physiology stomach, and this membrane needs to be elastic to enable the esophagus to move up and down. Normal physiology supports the gastroesophageal (GE)junction, where the esophagus and stomach join to move back and forth from just underneath to just above the diaphragm. However, at rest, the GE junction should be located below the diaphragm and in the abdominal cavity. It is essential to remember that these distances are very short.
Over time, the pharyngoesophageal membrane may become weaker, a portion of the stomach may herniate into the membrane and persist above the diaphragm permanently.
Decreased abdominal muscle tone and increased pressure within the abdominal city may start to the growth of a Hiatal hernia. Therefore, people who are overweight and women who are pregnant are at an elevated risk for developing a hiatal hernia.
People who have a repetitive vomiting or those who have constipation and strain to have bowel models increase the intra-abdominal pressure when they strain, and this may weaken the pharyngoesophageal membrane.
The membrane also may soften and lose its elasticity as a part of aging.
Ascites an abnormal accumulation of fluid in the abdominal cavity often observed in people with liver failure also, associated with the growth of a hiatal hernia.
Are there multiple types of a Hiatal Hernia?
The most common type of a hiatal hernia is a sliding hiatal hernia. This account for 95% of all hiatal hernias and, because a hiatus hernia by itself causes no symptoms, it is unknown how frequently his condition exists in the general population. With a sliding hernia, the GE junction and a portion of the stomach slide higher into the mediastinum, the area in the chest between the lungs where the esophagus advances and where the heart is located. A hernia is extra noticeable during aspiration when the diaphragm contracts and falls in the direction of the abdominal cavity and when the esophagus decreases during swallowing.
In a para esophageal hernia, the gap in the pharyngoesophageal membrane is large, and a larger portion of the stomach herniates into the chest adjacent the esophagus and stays there, but the GE junction stays below the diaphragm. This is due to ligaments that keep portions of the stomach connected to other organs inside the abdomen if a para-esophageal hernia happens, parts of the stomach rotate upward the assume that position above the diaphragm.
In a combination of events, should he defect in the diaphragm become large, the GE junction and addition regions of the stomach can herniate and become dislodged into the chest causing both a para esophageal and a sliding hiatus hernia.
What are the signs and symptoms of a hiatus hernia?
By itself, a hiatus hernia causes no symptoms, and most are found unexpectedly when a person has a chest X-ray or abdominal X ray or abdominal Xray including upper GI series, and CT scans, (where the patient swallows barium or different contrast material). It also is found incidentally during gastrointestinal endoscopy of the esophagus stomach and duodenum (ECD)
Most often if symptoms transpire, they are due to gastroesophageal reflux disease (GERD) where the digestive juices containing acid from the stomach moves up into the esophagus.
The stomach is like a mixing bowl that allows food and digestive juices to mix to begin the digestive process. The stomach has a protective lining that inhibits acid from eating away at the stomach muscle and producing inflammation. Unfortunately, the esophagus does not have a comparable protective lining. Instead, it relies on the lower esophageal sphincter (LES) located at the GE junction and the muscle of the diaphragm encircling the esophagus to function as a lid or plug to block acid from refluxing from the abdomen into the esophagus. In addition to the LES, the normal location of the GE junction within the abdominal cavity is important to keep the acid where it belongs. There is additional pressure in the chest cavity compared to the abdominal cavity, particularly during aspiration. This blend of pressure exerted within the lowermost esophagus from the LES, the diaphragm, and the abdominal cavity produces a zone of higher pressure that keeps stomach acid in place.
In cases with sliding hit hernia, The GE junction flows above the diaphragm and into the chest, and the higher pressure zone is dissipated. Acid is allowed to reflux back into the esophagus creating inflammation of the lining of the esophagus and the symptoms of GERD.
These symptoms may include the following:
- Buring in the esophagus region
- Waterbrash, the rapid emergence of a considerable amount of saliva in the mouth that is stimulated by
- the refluxing acid
- Heartburn; chest pain or burning
- Nausea, vomiting or retching (dry heaves)
Symptoms normally are worse after meals. These symptoms may be made worse when lying fast and may resolve with sitting up or walking.
In some subjects, reflux into the lower esophagus sets off nervous reflexes that can produce a cough or even spasm of the small airways within the lungs asthma. Some patients may have reflux acid droplets appear in the back of their throat. This acid can be breathed in or aspirated into the lung producing coughing spasms asthma or reoccurring infections of the lung including pneumonia and bronchitis. This may occur in an individual of all ages from infants to the elderly.
Most para esophageal vital hernias have no symptoms of reflux because the GE junction resides below the diaphragm, but because of the way the stomach has turned into the chest, there is the likelihood of a gastric volvulus where the stomach twist upon itself. Emergency and causes difficult, painful swallowing, chest pain, and vomiting.
How is a hiatal hernia diagnosed?
Most often, a hiatal hernia is found unexpectedly with gastronitiesnial X-rays, EGD and sometimes CT scan, since, by itself, it causes no symptoms. Only when there are linked, symptoms of GERD will the patient usually seek medical care. With symptoms of GERD, it is likely that a hiatal hernia exists in some form since most patients with GER have Hiatal hernias.
Most often, the diagnosis is established by a barium swallow or upper GI series, where a radiologist uses fluoroscopy to examine in real time as the swallowed barium outlines the esophagus, stomach and upper section of the small intestine. In addition to seeing the anatomy, the radiologist also can note the movement of the muscles that work to propel that barium (and presumably) food through the esophagus into the stomach and beyond.
Endoscopy is a medical operation performed under sedation by a gastroenterologist to look at the lining of the esophagus, stomach, and duodenum. A hiatus hernia may be diagnosed easily in this manner, and more importantly, the physician may be able to see complications of GEr from the reflux of acid. Endoscopy is to diagnose scarring with structure (narrowing of the esophagus and precancerous ailments like Barrett’s esophagus. Biopsies or small tissue specimens may be taken and examine under a microscope.
What is the treatment for a hiatal hernia?
The treatment for a hiatal hernia is a treatment for GERD and minimizing acid reflux. This includes decreasing acid secretion in the stomach, avoiding elements and substances that are vexatious to the stomach lining, and mechanical means to keep the residual acid in the stomach where it belongs.
Proton pump inhibitor medications are ordinarily used to decrease acid production. These include rabeprazole (Aciphex), pantoprazole (Protonix), esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilosec),
Lifestyle changes may include elevating your head while laying in bed, sleeping to allow gravity to limit acid from refluxing into the esophagus.
Small frequent meals may help rather than eating two or three large meals a day.
Some foods should be avoided including onions, citrus fruits, tomatoes, spicy food, however, most individuals are aware of the foods that trigger heartburn symptoms and evade them.
Hiatal Hernia Surgery
With the addition of proton pump inhibitor medications, medica
l therapy ha decreased the need of surgery for sliding hiatal hernias, and it is often only advised for people who have failed aggressive drug treatment or who have advanced complications of GERD, like ulcers, strictures, and bleeding, or those with chronic pneumonia from aspiration.
Patients with para esophageal hernias often have no symptoms, and surgery is required only if the hernias become confined and become stuck in the diaphragmatic hiatus or rotate to cause a volvulus. While this is more regularly seen in older people, para esophageal hernias also may occur as a congenital condition in neonates and infants.
Quite often, the surgery is performed as a minimally invasive operation utilizing a laparoscope. Although there are different methods, the results are comparable, and the best choice is usually the one the surgeon feels most relaxed performing in a specific circumstance.