Hiatal hernia (also called hiatus hernia) is a defect in the diaphragm that permits a portion of the stomach to pass through the diaphragmatic opening into the chest. It commonly produces no symptoms. Three types of hiatal hernia can occur: a sliding hernia, a paraesophageal (rolling) hernia, or a mixed hernia. A mixed hernia includes features of the sliding and rolling hernias.
The incidence of this disorder increases with age. By age 60, about 60% of people have hiatal hernias. However, most have no symptoms; the hernia is an incidental finding during a barium swallow, or it may be detected by tests that follow the discovery of occult blood. The prevalence (especially of the paraesophageal type) is higher in women than in men.
Suspected causes or contributing factors
Signs and Symptoms
The main symptoms are persistent heartburn and acid regurgitation. Some people have Hiatal Hernia without heartburn. Instead, they experience pain in the chest, hoarseness in the morning, or trouble swallowing. You may feel like you have food stuck in your throat or like you are choking or your throat is tight. Hiatal Hernia can also cause a dry cough and bad breath.
Chest X-ray occasionally shows an air shadow behind the heart in a large hernia; infiltrates appear in the lower lung lobes if the patient aspirated the refluxed fluids.
Barium swallow with fluoroscopy is the most specific test for detecting a hiatal hernia. The hernia may appear as an outpouching containing barium at the lower end of the esophagus. (Small hernias are difficult to recognize.) This study also shows diaphragmatic abnormalities.
Serum hemoglobin and hematocrit levels may be decreased in patients with paraesophageal hernia.
Endoscopy and biopsy are used to differentiate between hiatal hernia, varices, and other small gastroesophageal lesions. These tests are also used to identify the mucosal junction and the edge of the diaphragm indenting the esophagus and can be used to rule out cancer that might otherwise remain undetected.
Esophageal motility studies reveal esophageal motor or lower esophageal pressure abnormalities before surgical repair of the hernia.
pH studies are used to assess for reflux of gastric contents.
Acid perfusion test indicates that heartburn results from esophageal reflux when hydrochloric acid perfusion through a nasogastric tube provokes this symptom.
The goal of therapy is to relieve symptoms by minimizing or correcting the incompetent LES (if present) and to manage and prevent complications. Drugs, activity modifications, and diet changes reduce gastroesophageal reflux.
Antacids neutralize refluxed fluids; using antacids is probably the best treatment for intermittent reflux. Intensive antacid therapy may call for hourly dosing; however, the choice of antacids should take into account the patient's bowel function. Histamine-2 receptor antagonists also modify the acidity of fluid refluxed into the esophagus.
Drug therapy to strengthen LES tone may consist of a cholinergic agent such as bethanechol. Metoclopramide has also been used to stimulate smoothmuscle contraction, increase LES tone, and decrease, reflux after eating.
Other measures to reduce intermittent reflux include restricting any activity that increases intraabdominal pressure and discouraging smoking because it stimulates gastric acid production. Modifying the diet to include smaller, more frequent meals and eliminating spicy or irritating foods may also reduce reflux.
Rarely, surgery is required when symptoms persist despite medical treatment or if complications develop. Indications for surgery include esophageal stricture, significant bleeding, pulmonary aspiration, or incarceration or strangulation of the herniated stomach portion. Techniques vary, but most forms of surgery create an artificial closing mechanism at the gastroesophageal junction to strengthen the barrier function of the LES. The surgeon may use an abdominal or a thoracic approach.
Rare postsurgical complications include mucosal erosion, ulcers, and bleeding of the gastric pouch; pressure on the left lung due to the size and placement of the pouch; and formation of a volvulus.
A sliding hernia without an incompetent sphincter rarely produces reflux or symptoms and thus requires no treatment. A large rolling hernia should be surgically repaired (even if it produces no symptoms) because of the high risk of complications, especially strangulation.
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