HIATAL HERNIA
A hiatal hernia is a condition where the top of your stomach bulges through an opening in your
diaphragm. This can happen to people of any age and any gender. A hiatal hernia doesn’t always
have symptoms, but when it does they are similar to the symptoms of GERD.
A hiatal hernia occurs when the upper part of the stomach pushes through an opening in the
diaphragm and into the chest cavity. The diaphragm is the thin muscle wall that separates the
chest cavity from the abdomen. The opening in the diaphragm is where the esophagus and
stomach join.
The esophagus sphincter muscle normally closes tightly. With a hiatal hernia, the sphincter’s new
position may keep it from completely closing. The back flow of digestive juices may damage the
esophagus.
Types Of Hiatal Hernia
There are 2 types of hiatal hernia.
Sliding hiatal hernia:
• The sliding type, as its name implies, occurs when the junction between the
stomach and esophagus slides up through the esophageal hiatus during
moments of increased pressure in the abdominal cavity.
• When the pressure is relieved, the stomach falls back down with gravity to its
normal position.
• Approximately 90% of all hiatal hernias are the sliding type.
Paraesophageal hiatal hernia
• In paraesophageal hiatal there is no sliding up and down. A portion of the
stomach remains stuck in the chest cavity.
• These hernias remain in the chest at all times.
• This type is less common.
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➢ RISK FACTORS
Who is at risk for developing a hiatal hernia?
A hiatal hernia can develop in people of all ages and both sexes, although it frequently occurs in
people age 50 and older. Hiatal hernia occurs more often in overweight people and smokers.
➢ SYMPTOMS AND CAUSES
What causes a hiatal hernia?
The most common cause of a hiatal hernia is an increase in pressure in the abdominal
cavity. Your abdominal cavity is the space in the middle of your body that holds several
organs, including the:
• Lower part of the esophagus and stomach.
• Small intestine, colon and rectum.
• Liver.
• Gallbladder, pancreas and spleen.
• Kidneys.
• Bladder.
This pressure can build up from things like:
• Coughing.
• Vomiting.
• Straining during a bowel movement.
• Heavy lifting.
• Physical strain.
There are also other reasons a hiatal hernia could develop. You may experience a hiatal
hernia during pregnancy, if you are obese, or if there’s extra fluid in your abdomen.
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What are the symptoms of a hiatal hernia?
Many people with a hiatal hernia never have symptoms. Some people with hiatal hernia
have some of the same symptoms as gastroesophageal reflex disease (GERD). GERD
occurs when digestive juices move from the stomach back into the esophagus. Symptoms
of GERD include:
• Heartburn.
• Bitter or sour taste in the back of the throat.
• Bloating and belching.
• Discomfort or pain in the stomach or esophagus.
Although there appears to be a link between hiatal hernia and GERD, one condition does
not seem to cause the other. Many people have a hiatal hernia without having GERD, and
others have GERD without having a hiatal hernia.
Another symptom of a hiatal hernia is chest pain. Since chest pain can also be a symptom
of a heart attack, it’s important to contact your healthcare provider or go to the
emergency room if you experience any chest pain.
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➢ PATHOPHYSIOLOGY
PREDISPOSING FACTOR: PRECIPITATING FACTOR:
•Age • Weight lifting
• Heavy Activity
• Constipation
• Pregnancy
• Tightening of clothes
around abdomen
Permanent shortening of the esophagus Gastro-esophageal junction displacement
Reflux and regurgitation of stomach acid Decrease lower esophageal (LEL) pressure
Inflammation and scarring of esophagus Incompetent gastro-esophageal hiatus
Shortening of esophagus Large opening of esophageal
Stomach herniates through the hiatus into the chest
Clinical Manifestation
(Heartburn, chestpain)
Hiatal hernia
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➢ DIAGNOSIS
How is a hiatal hernia diagnosed?
Several tests can be done to help diagnose a hiatal hernia. These include a barium swallow
test, an endoscopy procedure, esophageal manometric studies, a pH test and gastric
emptying studies.
• A barium swallow involves drinking a special liquid, then taking X-rays to help see
problems in the esophagus (such as swallowing disorders) and the stomach (such
as ulcers and tumors). It also shows how big the hiatal hernia is and if there is
twisting of the stomach as a result of the hernia.
• An endoscopy is a procedure in which the inside of the upper digestive system is
viewed with an endoscope (a long, thin, flexible instrument about 1/2 inch in
diameter).
• An esophageal manometry measures the strength and muscle coordination of
your esophagus when you swallow.
• A pH test measures the acid levels in the esophagus and helps determine which
symptoms are related to acid in the esophagus.
• Gastric emptying studies examine how fast food leaves the stomach. Results from
this test are especially important in patients who have nausea and vomiting. There
could be other causes of the nausea and vomiting besides a hiatal hernia.
➢ MANAGEMENT AND TREATMENT
How is a hiatal hernia treated?
Most hiatal hernias do not cause problems and rarely need treatment. However, since
some patients with a hiatal hernia have symptoms of GERD, treatment starts with
methods used to manage GERD. These include making such lifestyle changes as:
• Losing weight if you’re overweight.
• Decreasing the portion sizes of meals.
• Avoiding certain acidic foods—such as tomato sauce and citrus fruits or juices—
that can irritate the esophageal lining.
• Limiting fried and fatty foods, foods or drinks containing caffeine (including
chocolate), peppermint, carbonated beverages, alcoholic beverages, ketchup and
mustard, and vinegar.
• Eating meals at least three to four hours before lying down, and avoiding bedtime
snacks.
• Keeping your head six inches higher than the rest of your body when lying on your
back. Raising the level of your head helps gravity keep your stomach’s contents in
the stomach. Raising the head of your bed by angling your mattress works best—
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piling your pillows doesn’t work as well because it makes you crunch your middle
instead of simply angling your body upwards.
• Quitting smoking.
• Not wearing a tight belt or tight clothing that can increase the pressure on the
abdomen — such as control top hosiery and body shapers.
• Taking medications after eating to reduce acid in the stomach. These over-the-
counter medications include antacids, Gaviscon®, or H-blockers (such as Pepcid
AC® or Zantac®).
Sometimes, a medication called a proton-pump inhibitor might be used to treat hiatal
hernia. This medication is another way to decrease the amount of stomach acid you have,
which can help prevent reflux. When you take this medication, your body doesn’t make
as much stomach acid as normal. This is similar to H-blocker medications.
➢ PROGNOSIS
How effective is surgery for a hiatal hernia?
A laparoscopic repair of hiatal hernia and reflux, called Nissen Fundoplication, is very
effective in most patients. This surgery requires general anesthesia and a short stay in the
hospital. If you need to have an open surgical procedure, the recovery time will be longer
and you may need to stay in the hospital for several days. After surgery, most patients no
longer require long-term treatment with prescription or over-the-counter antacid
medications.
➢ What is the connection between GERD and hiatal hernias?
Gastroesophageal reflux disease (GERD) occurs when the food, liquids, and acid in your
stomach end up in your esophagus. This can lead to heartburn or nausea after meals.
It’s common for people with a hiatal hernia to have GERD. However, that doesn’t mean
either condition always causes the other. You can have a hiatal hernia without GERD or
GERD without a hernia.
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