Hiatal hernia is a defect in the diaphragm that permits a portion of the stomach to pass through the diaphragmatic opening into the chest. Three types of hiatal hernia can occur: sliding hernia, paraesophageal (rolling) hernia, and mixed hernia, which includes features of both. (See Two types of hiatal hernia.)
In a sliding hernia, both the stomach and the gastroesophageal junction slip up into the chest, so that the gastroesophageal junction is above the diaphragmatic hiatus. In paraesophageal hernia, a part of the greater curvature of the stomach rolls through the diaphragmatic defect. Treatment can prevent such complications as strangulation of the herniated intrathoracic portion of the stomach.
Usually, hiatal hernia results from muscle weakening that’s common with aging and may be secondary to esophageal cancer, kyphoscoliosis, trauma, and certain surgical procedures. It may also result from certain diaphragmatic malformations that may cause congenital weakness.
In hiatal hernia, the muscular collar around the esophageal and diaphragmatic junction loosens, permitting the lower portion of the esophagus and the stomach to rise into the chest when intra-abdominal pressure increases (possibly causing gastroesophageal reflux). Such increased intra-abdominal pressure may result from ascites, pregnancy, obesity, constrictive clothing, bending, straining, coughing, Valsalva’s maneuver, or extreme physical exertion.
A sliding hernia is 3 to 10 times more common than paraesophageal and mixed hernias combined. In fact, sliding hernias comprise 90% of hiatal hernias. The incidence of hiatal hernia is higher in women than in men (especially the paraesophageal type) and increases with age.
Typically, a paraesophageal hernia produces no symptoms; it’s usually an incidental finding on barium swallow. Because this type of hernia leaves the closing mechanism of the cardiac sphincter unchanged, it seldom causes acid reflux and reflux esophagitis.
Symptoms result from displacement or stretching of the stomach and may include a feeling of fullness in the chest or pain that resembles angina pectoris. Even if it produces no symptoms, this type of hernia needs surgical treatment because of the high risk of strangulation.
A sliding hernia without an incompetent sphincter produces no reflux or symptoms and, consequently, doesn’t require treatment. When a sliding hernia does cause symptoms, they’re typical of gastric reflux (resulting from the incompetent lower esophageal sphincter [LES]) and may include the following:
❑ Pyrosis (heartburn) occurs from 1 to 4 hours after eating and is aggravated by reclining, belching, and increased intra-abdominal pressure. It may be accompanied by regurgitation or vomiting.
❑ Retrosternal or substernal chest pain results from reflux of gastric contents, distention of the stomach, and spasm or altered motor activity. Chest pain occurs most commonly after meals or at bedtime and is aggravated by reclining, belching, and increased intra-abdominal pressure.
Other common symptoms reflect possible complications. Symptoms are aggravated with any increase in intra-abdominal pressure.
❑ Dysphagia occurs when the hernia produces esophagitis, esophageal ulceration, or stricture, especially with ingestion of very hot or cold foods, alcoholic beverages, or a large amount of food.
❑ Bleeding may be mild or massive, frank or occult; the source may be esophagitis or erosions of the gastric pouch.
❑ Severe pain and shock result from incarceration, in which a large portion of the stomach is caught above the diaphragm. (This usually occurs with paraesophageal hernia.) Incarceration may lead to the perforation of a gastric ulcer as well as strangulation and gangrene of the herniated portion of the stomach. This requires immediate surgery.
Hiatal hernia is diagnosed based on typical clinical features and the results of the following laboratory studies and procedures:
❑ Chest X-ray occasionally shows an air shadow behind the heart with a large hernia and infiltrates in the lower lobes if the patient has aspirated.
❑ In a barium study, the hernia may appear as an outpouching that contains barium at the lower end of the esophagus. (Small hernias are difficult to recognize.) This study also shows diaphragmatic abnormalities.
❑ Endoscopy and biopsy differentiate between hiatal hernia, varices, and other small gastroesophageal lesions; identify the mucosal junction and the edge of the diaphragm indenting the esophagus; and can rule out malignant tumors that otherwise might be difficult to detect.
❑ Esophageal motility studies assess the presence of esophageal motor abnormalities before surgical repair of the hernia.
❑ pH studies assess for reflux of gastric contents.
❑ Acid perfusion (Bernstein) test indicates that heartburn results from esophageal reflux when perfusion of hydrogen chloride through the nasogastric (NG) tube provokes this symptom.
The following laboratory tests may indicate GI bleeding as a complication of hiatal hernia:
❑ Complete blood count may show hypochromic microcytic anemia when bleeding from esophageal ulceration occurs.
❑ Stool guaiac test may be positive.
❑ Analysis of gastric contents may reveal blood.
The primary goals of treatment are to relieve symptoms by minimizing or correcting the incompetent cardia and to manage and prevent complications. Medical therapy is used initially because symptoms usually respond to it and hiatal hernia may recur after surgery.
Medical therapy attempts to modify or reduce reflux by changing the quantity or quality of refluxed gastric contents, strengthening the LES muscle pharmacologically, or decreasing the amount of reflux through gravity.
Specific measures include restricting any activity that increases intra-abdominal pressure (coughing, straining, bending), avoiding constrictive clothing, modifying diet, and discouraging smoking because it stimulates gastric acid production.
Modifying the diet means eating small, frequent meals at least 2 hours before lying down (no bedtime snacks); eating slowly; and avoiding irritating foods, alcoholic beverages, and coffee. Antacids also modify the fluid refluxed into the esophagus and are probably the best treatment for intermittent reflux.
To reduce the amount of reflux, the overweight patient should lose weight to decrease intra-abdominal pressure. Elevating the head of the bed about 6" (15 cm) reduces gastric reflux by gravity.
Drug therapy to strengthen cardiac sphincter tone may include a cholinergic agent such as bethanechol. Metoclopramide has also been used to stimulate smooth-muscle contraction, increase LES tone, and decrease reflux after eating.
Failure to control symptoms medically or the onset of such complications as stricture, bleeding, pulmonary aspiration, strangulation, or incarceration necessitates an antireflux surgical repair.
Surgery creates an artificial closing mechanism at the gastroesophageal junction to strengthen the LES’s barrier function. A transabdominal fundoplication is performed by wrapping the fundus of the stomach around the lower esophagus to prevent reflux of stomach contents. An abdominal or a thoracic approach may be used. Laparoscopic surgery to repair the hernia is now commonplace. A newer treatment involves thoroscopic surgery, with the hernia repaired microscopically.
❑ To enhance compliance with treatment, instruct the patient about the causes of this disorder. Explain proposed treatments, diagnostic tests, and significant symptoms.
❑ Prepare the patient for diagnostic tests, as needed. After endoscopy, watch for signs of perforation (falling blood pressure, rapid pulse, shock, and sudden pain).
❑ Before surgery, reinforce patient teaching about the procedure and any preoperative and postoperative considerations.
❑ Postoperatively, monitor intake and output, including NG tube drainage.
Clinical tip Never manipulate an NG tube in a patient with a hiatal hernia surgical repair.
❑ If a thoracic approach was used, the patient will have chest tubes in place. Carefully observe chest tube drainage and respiratory status, and perform pulmonary physiotherapy.
❑ Monitor NG tube patency and security to prevent distention of the stomach during the healing period. Distention can cause a breakdown of the repair.
❑ Instruct the patient that a barium swallow will be performed on the 6th or 7th postoperative day to look for the unobstructed passage of barium into the stomach before starting solid foods.
❑ Inform the patient that slight dysphagia may be experienced in the first few weeks after surgery. This will gradually disappear.
❑ Instruct the patient to eat small, frequent meals.
❑ Counsel the patient that increased flatus and mild gastric distention may occur due to trapping of air in the stomach from air swallowing. Air swallowing should be consciously avoided.
❑ Instruct the patient to take all medications in liquid or crushed form for at least 6 months to avoid a drug-induced esophageal injury.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Handbook of Diseases Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2003 ISBN: 1-58255-266-5 
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