Hiatus hernia

Ventricular hernia
Classification and external resources
ICD-10	K44, Q40.1
ICD-9	553.3, 750.6
OMIM	142400
DiseasesDB	29116
MedlinePlus	001137
eMedicine	med/1012 radio/337
MeSH	D006551

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.

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 type.

There are two major kinds of hiatus hernia: ^[1]

• 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 hiatus and lies beside the esophagus, without movement of the gastroesophageal junction. It accounts for the remaining 5% of hiatus hernias. ^[2]

A third kind is also sometimes described, and is a combination of the first and second kinds.^{[citation needed]}

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 diaphragm), 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.

Risk factors

The following are risk factors that can result in a hiatus hernia.

• Increased pressure within the abdomen caused by:
  • Heavy lifting or bending over
  • Frequent or hard coughing
  • Hard sneezing
  • Pregnancy and delivery
  • Violent vomiting
  • Straining with constipation
  • Obesity (extra weight pushes down on the abdomen increasing the pressure)
  • Use of the sitting position for defecation^[3] (See epidemiology below)
• Heredity
• Smoking^{[citation needed]}
• Drug use, such as cocaine^{[citation needed]}
• Stress
• Diaphragm weakness^{[citation needed]}

Diagnosis

A large hiatus hernia on X-ray marked by open arrows in contrast to the heart borders marked by closed arrows

Upper GI endoscopy depicting hiatus hernia

A hiatus hernia as seen on CT

The diagnosis of a hiatus hernia is typically made through an upper GI series, endoscopy or high resolution manometry.

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 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 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.^[4]

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.

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 disease (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.^{[citation needed]}

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.

Epidemiology

Incidence of hiatal hernias increases with age; approximately 60% of individuals aged 50 or older have a hiatal hernia.^[5] 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."^[3] 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.^[6]

Notes and references

1. ^ 01011 at CHORUS
2. ^ Lawrence, P. (1992). Essentials of General Surgery. Baltimore: Williams & Wilkins. p. 178. ISBN 0-683-04869-4. 
3. ^ ^{a b} Burkitt DP (1981). "Hiatus hernia: is it preventable?". Am. J. Clin. Nutr. 34 (3): 428–31. PMID 6259926. http://www.ajcn.org/cgi/reprint/34/3/428.pdf. 
4. ^ Lange CMDT 2006
5. ^ Goyal Raj K, "Chapter 286. Diseases of the Esophagus". Harrison's Principles of Internal Medicine, 17e.
6. ^ Sontag S (1999). "Defining GERD". Yale J Biol Med 72 (2-3): 69–80. PMC 2579007. PMID 10780568. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=2579007. 

External links

• 01011 at CHORUS