Hiatal hernia

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Hiatus hernia
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Hiatal hernia
Other namesHiatus hernia
proton pump inhibitors[1]
Frequency10–80% (US)[1]

A hiatal hernia or hiatus hernia

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: sliding hernia, in which the body of the stomach moves up; and 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 hiatal hernia may be improved by changes such as raising the head of the bed, weight loss, and adjusting eating habits.

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

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,

heart palpitations (due to irritation of the vagus nerve), and swallowed food "balling up" and causing discomfort in the lower esophagus until it passes on to the 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[4] from symptoms such as difficulty breathing,[5] fast respiration, and increased heart rate.[6]

Causes

The following are potential causes of a hiatal hernia.[7]

Obesity and age-related changes to the diaphragm are also general risk factors.

Diagnosis

The diagnosis of a hiatal hernia is typically made through an

computed tomography
(CT). Barium swallow as in upper GI series allows the size, location, stricture, stenosis of oesophagus to be seen. It can also evaluate the oesophageal movements. Endoscopy can analyse the esophageal internal surface for erosions, ulcers, and tumours.

Meanwhile, manometry can determine the integrity of esophageal movements, and the presence of esophageal achalasia. pH testings allows the quantitative analysis of acid reflux episodes. CT scan is useful in diagnosing complications of hiatal hernia such as gastric volvulus, perforation, pneumoperitoneum, and pneumomediastinum.[8]

  • A large hiatal hernia on chest X-ray marked by open arrows in contrast to the heart borders marked by closed arrows
    A large hiatal hernia on
    chest X-ray
    marked by open arrows in contrast to the heart borders marked by closed arrows
  • This hiatal hernia is mainly identified by an air-fluid level (labeled with arrows).
    This hiatal hernia is mainly identified by an air-fluid level (labeled with arrows).
  • Upper GI endoscopy depicting hiatal hernia
    Upper GI endoscopy
    depicting hiatal hernia
  • Upper GI endoscopy in retroflexion showing Type I hiatal hernia
    Upper GI endoscopy
    in retroflexion showing Type I hiatal hernia
  • A hiatal hernia as seen on CT
    A hiatal hernia as seen on CT
  • A large hiatal hernia as seen on CT imaging
    A large hiatal hernia as seen on CT imaging
  • A large hiatal hernia as seen on CT imaging
    A large hiatal hernia as seen on CT imaging
  • As seen on ultrasound[9]
  • As seen on ultrasound[9]

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:[10]

Type I: A type I hernia, also known as a sliding hiatal hernia, occurs when part of the stomach slides up through the hiatal opening in the diaphragm.[11] There is a widening of the muscular hiatal tunnel and circumferential laxity of the phrenoesophageal ligament, 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.[12] (C)

Type II: A type II hernia, also known as a paraesophageal or rolling hernia, occurs when the fundus and greater curvature of the stomach roll up through the diaphragm, forming a pocket alongside the esophagus.[11] It results from a localized defect in the phrenoesophageal ligament 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 ligament 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 ligament, 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, people experience no significant discomfort, and no treatment is required. People with symptoms should elevate the head of their beds and avoid lying down directly after meals.[1] If the condition has been brought on by stress, stress reduction techniques may be prescribed, or if overweight, weight loss may be indicated.

Medications

Antisecretory drugs such as

lower esophageal sphincter (LES) pressure should be avoided.[citation needed
]

Procedures

There is tentative evidence from non-controlled trials that oral neuromuscular training may improve symptoms.[13] This has been approved by the UK National Health Service for supply on prescription from 1 May 2022.[14]

Surgery

In some unusual instances, as when the hiatal hernia is unusually large, or is of the paraesophageal type, it may cause

achalasia.[15][16]
Surgical procedures sometimes fail over time, requiring a second surgery to make repairs.

One surgical procedure used is called

fundoplication studies in the 21st century have indicated relatively low complication rates, quick recovery, and relatively good long term results.[17][18][19][20]
Regarding the discussion of partial versus complete fundoplication procedures, significant variations in the postoperative outcome emphasize the increased prevalence of dysphagia after Nissen. The statistics given support the superiority of laparoscopic over traditional surgery, owing to the greater aesthetic result, shorter admission time – with lower costs – and faster social reintegration.[21]

Epidemiology

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

lower esophageal sphincter (LES). 95% of these are "sliding" hiatal 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.[citation needed
]

Hiatal hernias are most common in North America and Western Europe and rare in rural African communities.

sitting position for defecation may increase the risk.[24]

References

  1. ^
    S2CID 7141090
    . However, the exact prevalence of hiatus hernia is difficult to determine because of the inherent subjectivity in diagnostic criteria. Consequently, estimates vary widely—for example, from 10% to 80% of the adult population in North America
  2. ^ "Hiatus hernia - Illnesses & conditions". NHS inform. Retrieved 10 May 2022.
  3. ^ a b "Hiatal Hernia". PubMed Health. Archived from the original on 28 April 2017.
  4. PMID 20225535
    .
  5. PMID 23810174
    .
  6. PMID 27407781
    .
  7. ^ "Hiatal hernia - Symptoms and causes". Mayo Clinic.
  8. PMID 31750430
    .
  9. ^ a b "UOTW #39 - Ultrasound of the Week". Ultrasound of the Week. 25 February 2015. Archived from the original on 9 May 2017. Retrieved 27 May 2017.
  10. PMID 18656819
    .
  11. ^
    OCLC 944472408.{{cite book}}: CS1 maint: location missing publisher (link
    )
  12. ISBN 978-0071802154
    .
  13. ^ Clinical and technical evidence - IQoro for hiatus hernia (Report). National Institute for Health and Care Excellence. 6 March 2019. MIB176.
  14. ^ "Innovative IQoro neuromuscular treatment device achieves NHS prescription status". Advances in Clinical Neuroscience and Rehabilitation (ACNR). 25 March 2022.
  15. ^
    PMID 12368678
    .
  16. ^ Laparoscopic Nissen fundoplication - Information for patients (PDF) (Report). Oxford University Hospitals NHS. December 2021. OMI68160.
  17. PMID 23837098
    .
  18. PMID 22648098
    .
  19. S2CID 25195984
    .
  20. PMID 14759403
    .
  21. PMID 22802887
    .
  22. ^ Goyal Raj K, "Chapter 286. Diseases of the Esophagus". Harrison's Principles of Internal Medicine, 17e.
  23. PMID 6259926
    .
  24. PMID 10780568
    .

External links

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