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Hiatus Hernia

Updated : May 24, 2024





Background

Hiatus hernia, also known as hiatal hernia, is a condition that occurs when a portion of the stomach pushes through the diaphragm and into the chest cavity. The hiatus is an opening in the diaphragm through which the esophagus passes before entering the stomach in the abdominal cavity.

There are two main types of hiatus hernia:

Sliding Hiatus Hernia: This is the more common type. In a sliding hernia, a portion of the stomach and the junction where the esophagus and stomach meet (gastroesophageal junction) slide up through the hiatus into the chest cavity. When a person lies down or stands up, the herniated portion can move back and forth.

Paraesophageal Hiatus Hernia: This type is less common but more concerning. In a paraesophageal hernia, a portion of the stomach pushes through the hiatus and lies next to the esophagus in the chest cavity. This type of hernia can become trapped, leading to complications like strangulation or reduced blood flow to the herniated portion.

Epidemiology

The incidence of hiatal hernias exhibits a noticeable rise in correlation with advancing age. Approximately 55% to 60% of individuals aged 50 and above are affected by this condition. Notably, a mere 9% of this demographic experience discernible symptoms. This variance hinges on the specific type of hernia and the effectiveness of the lower esophageal sphincter (LES).

The predominant portion of these hernias, approximately 95%, fall under the category of type I sliding hiatal hernias. Within this classification, the LES allows movement, resulting in the stomach slipping through the diaphragm. The remaining 5% corresponds to type II paraesophageal hernias, in which the LES remains stationary while the stomach protrudes above the diaphragm.

This distinction underscores the diversity of hiatal hernias and their varying characteristics. Among the factors influencing the occurrence, women have an increased prevalence. This discrepancy could be attributed to the augmented intraabdominal pressure experienced during pregnancy, which might contribute to the development of hiatal hernias.

Moreover, the distribution of hiatal hernias across different regions is not uniform. The condition is notably more prevalent in Western Europe and North America, whereas its occurrence is notably rare in rural Africa. This geographical variation underscores the interplay of lifestyle, genetic predisposition, and environmental factors in the prevalence of hiatal hernias.

Anatomy

Pathophysiology

The pathophysiology of hiatal hernia involves weakening of the structures that maintain the normal anatomy. Over time, the muscles and connective tissues that make up the diaphragm may weaken. This weakening can lead to an enlargement of the hiatus, allowing a portion of the stomach to slide up into the chest cavity. This is known as a sliding hiatal hernia.

Conditions that cause increased pressure within the abdomen such as obesity, pregnancy, heavy lifting, and persistent coughing—can contribute to the development of hiatal hernias. The pressure pushes the stomach through the weakened diaphragm opening. The displaced stomach can allow stomach acid and contents to flow back into the esophagus, causing symptoms like heartburn, regurgitation, and a sour taste in the mouth.

Etiology

Hiatal hernias can arise either due to congenital factors or as a result of acquired conditions. They are notably more prevalent in older individuals. The underlying mechanism behind this increased prevalence involves the weakening of muscles accompanied by a decline in flexibility and elasticity that commonly occurs with advancing age. This weakening makes individuals more susceptible to the emergence of a hiatal hernia.

Consequently, the upper portion of the stomach might fail to return to its natural position below the diaphragm during swallowing. Numerous additional factors have been identified as predisposing individuals to the development of hiatal hernias. Among these, elevated intraabdominal pressure stands out. This pressure elevation is frequently linked to obesity, pregnancy, chronic constipation, and chronic obstructive pulmonary disease (COPD).

The likelihood of a hiatal hernia is notably increased in cases where these factors are present. Beyond these primary contributors, a range of other elements can also contribute to the genesis of a hiatal hernia. Trauma, the natural process of aging, previous surgeries, and genetic factors all play influential roles in creating an environment conducive to the emergence of a hiatal hernia.

Genetics

Prognostic Factors

The effectiveness of hiatal hernia surgery can be assessed based on several criteria, including symptom alleviation, reduction in esophageal acid exposure, occurrence of complications, and the necessity for reoperation.

In a specific instance, a prospective study tracked 100 patients who underwent antireflux surgery over a decade, revealing an impressive 90% decrease in symptoms after 10 years.

This finding underscores the enduring benefits of the surgical intervention. Notably, advancements in operative techniques over the last 20 years have led to overall enhanced outcomes in the collective experience with surgical management.

Clinical History

Clinical History

Hiatal hernias become more prevalent with age, especially in individuals over 50. Conditions like obesity, pregnancy, chronic obstructive pulmonary disease (COPD), and chronic straining (e.g., constipation) can increase the risk. Smoking, heavy lifting, and dietary habits can contribute to the development of hiatal hernias. The signs and symptoms of hiatal hernia can vary, and not everyone with a hiatal hernia experience symptoms.

The most common symptom is a burning sensation in the chest or throat due to stomach acid flowing back into the esophagus. The onset of symptoms can vary. Some individuals might experience gradual symptom development, while others might notice symptoms suddenly. The duration of symptoms can also vary widely, ranging from occasional episodes to persistent discomfort.

Physical Examination

Physical Examination

Physical examination is typically of limited utility in definitively confirming the diagnosis of hiatal hernia and gastroesophageal reflux disease (GERD) in patients. However, it plays a crucial role in identifying alarming signs that could indicate more severe conditions.

For instance, identifying unusual supraclavicular lymph nodes in patients experiencing heartburn and dysphagia can raise suspicion of esophageal or gastric cancer. This observation holds significant importance as part of the comprehensive evaluation process. In some cases, a visible or palpable abdominal bulge might be present, indicating the herniation of the stomach into the chest cavity.

Age group

Associated comorbidity

Associated activity

Acuity of presentation

Differential Diagnoses

Differential Diagnoses

Primary Lung Disease

Esophageal Cancer

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Surgical Care

The emergence of proton pump inhibitors (PPIs) has led to a shift in the criteria for considering surgical intervention. Patients exhibiting severe esophageal injury indicators like ulcers, strictures, or Barrett’s mucosa are now potential candidates for surgical treatment. Furthermore, individuals with prolonged symptom duration or those who do not experience complete symptom relief with medical therapy should also be evaluated for surgical options.

The evolution of minimally invasive techniques for GERD treatment has contributed to a reduction in surgical costs. Consequently, patients with an anticipated life expectancy exceeding 8 years and requiring lifelong therapy due to a mechanically impaired lower esophageal sphincter might find surgical intervention to be the preferred therapeutic avenue. This paradigm underscores the value of surgical solutions in appropriately selected cases, enhancing the overall treatment landscape for GERD.

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

Medication

Media Gallary

References

Hiatus Hernia

Updated : May 24, 2024




Hiatus hernia, also known as hiatal hernia, is a condition that occurs when a portion of the stomach pushes through the diaphragm and into the chest cavity. The hiatus is an opening in the diaphragm through which the esophagus passes before entering the stomach in the abdominal cavity.

There are two main types of hiatus hernia:

Sliding Hiatus Hernia: This is the more common type. In a sliding hernia, a portion of the stomach and the junction where the esophagus and stomach meet (gastroesophageal junction) slide up through the hiatus into the chest cavity. When a person lies down or stands up, the herniated portion can move back and forth.

Paraesophageal Hiatus Hernia: This type is less common but more concerning. In a paraesophageal hernia, a portion of the stomach pushes through the hiatus and lies next to the esophagus in the chest cavity. This type of hernia can become trapped, leading to complications like strangulation or reduced blood flow to the herniated portion.

The incidence of hiatal hernias exhibits a noticeable rise in correlation with advancing age. Approximately 55% to 60% of individuals aged 50 and above are affected by this condition. Notably, a mere 9% of this demographic experience discernible symptoms. This variance hinges on the specific type of hernia and the effectiveness of the lower esophageal sphincter (LES).

The predominant portion of these hernias, approximately 95%, fall under the category of type I sliding hiatal hernias. Within this classification, the LES allows movement, resulting in the stomach slipping through the diaphragm. The remaining 5% corresponds to type II paraesophageal hernias, in which the LES remains stationary while the stomach protrudes above the diaphragm.

This distinction underscores the diversity of hiatal hernias and their varying characteristics. Among the factors influencing the occurrence, women have an increased prevalence. This discrepancy could be attributed to the augmented intraabdominal pressure experienced during pregnancy, which might contribute to the development of hiatal hernias.

Moreover, the distribution of hiatal hernias across different regions is not uniform. The condition is notably more prevalent in Western Europe and North America, whereas its occurrence is notably rare in rural Africa. This geographical variation underscores the interplay of lifestyle, genetic predisposition, and environmental factors in the prevalence of hiatal hernias.

The pathophysiology of hiatal hernia involves weakening of the structures that maintain the normal anatomy. Over time, the muscles and connective tissues that make up the diaphragm may weaken. This weakening can lead to an enlargement of the hiatus, allowing a portion of the stomach to slide up into the chest cavity. This is known as a sliding hiatal hernia.

Conditions that cause increased pressure within the abdomen such as obesity, pregnancy, heavy lifting, and persistent coughing—can contribute to the development of hiatal hernias. The pressure pushes the stomach through the weakened diaphragm opening. The displaced stomach can allow stomach acid and contents to flow back into the esophagus, causing symptoms like heartburn, regurgitation, and a sour taste in the mouth.

Hiatal hernias can arise either due to congenital factors or as a result of acquired conditions. They are notably more prevalent in older individuals. The underlying mechanism behind this increased prevalence involves the weakening of muscles accompanied by a decline in flexibility and elasticity that commonly occurs with advancing age. This weakening makes individuals more susceptible to the emergence of a hiatal hernia.

Consequently, the upper portion of the stomach might fail to return to its natural position below the diaphragm during swallowing. Numerous additional factors have been identified as predisposing individuals to the development of hiatal hernias. Among these, elevated intraabdominal pressure stands out. This pressure elevation is frequently linked to obesity, pregnancy, chronic constipation, and chronic obstructive pulmonary disease (COPD).

The likelihood of a hiatal hernia is notably increased in cases where these factors are present. Beyond these primary contributors, a range of other elements can also contribute to the genesis of a hiatal hernia. Trauma, the natural process of aging, previous surgeries, and genetic factors all play influential roles in creating an environment conducive to the emergence of a hiatal hernia.

The effectiveness of hiatal hernia surgery can be assessed based on several criteria, including symptom alleviation, reduction in esophageal acid exposure, occurrence of complications, and the necessity for reoperation.

In a specific instance, a prospective study tracked 100 patients who underwent antireflux surgery over a decade, revealing an impressive 90% decrease in symptoms after 10 years.

This finding underscores the enduring benefits of the surgical intervention. Notably, advancements in operative techniques over the last 20 years have led to overall enhanced outcomes in the collective experience with surgical management.

Clinical History

Hiatal hernias become more prevalent with age, especially in individuals over 50. Conditions like obesity, pregnancy, chronic obstructive pulmonary disease (COPD), and chronic straining (e.g., constipation) can increase the risk. Smoking, heavy lifting, and dietary habits can contribute to the development of hiatal hernias. The signs and symptoms of hiatal hernia can vary, and not everyone with a hiatal hernia experience symptoms.

The most common symptom is a burning sensation in the chest or throat due to stomach acid flowing back into the esophagus. The onset of symptoms can vary. Some individuals might experience gradual symptom development, while others might notice symptoms suddenly. The duration of symptoms can also vary widely, ranging from occasional episodes to persistent discomfort.

Physical Examination

Physical examination is typically of limited utility in definitively confirming the diagnosis of hiatal hernia and gastroesophageal reflux disease (GERD) in patients. However, it plays a crucial role in identifying alarming signs that could indicate more severe conditions.

For instance, identifying unusual supraclavicular lymph nodes in patients experiencing heartburn and dysphagia can raise suspicion of esophageal or gastric cancer. This observation holds significant importance as part of the comprehensive evaluation process. In some cases, a visible or palpable abdominal bulge might be present, indicating the herniation of the stomach into the chest cavity.

Differential Diagnoses

Primary Lung Disease

Esophageal Cancer

Surgical Care

The emergence of proton pump inhibitors (PPIs) has led to a shift in the criteria for considering surgical intervention. Patients exhibiting severe esophageal injury indicators like ulcers, strictures, or Barrett’s mucosa are now potential candidates for surgical treatment. Furthermore, individuals with prolonged symptom duration or those who do not experience complete symptom relief with medical therapy should also be evaluated for surgical options.

The evolution of minimally invasive techniques for GERD treatment has contributed to a reduction in surgical costs. Consequently, patients with an anticipated life expectancy exceeding 8 years and requiring lifelong therapy due to a mechanically impaired lower esophageal sphincter might find surgical intervention to be the preferred therapeutic avenue. This paradigm underscores the value of surgical solutions in appropriately selected cases, enhancing the overall treatment landscape for GERD.