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. Hiatal hernia is the most common problem of the diaphragm affecting the alimentary canal. Two types of hiatal hernia can occur: sliding hernia and paraesophageal hernia. (See Types of hiatal hernia.) In a sliding hernia, the stomach and the gastroesopha-geal junction slip up into the chest, so 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 complications such as strangulation of the herniated intrathoracic portion of the stomach.
Hiatal hernia typically results from muscle weakening that’s common with aging and may be secondary to esophageal carcinoma, kyphoscoliosis, trauma, or certain surgical procedures. It may also result from certain diaphragmatic malformations that may cause congenital weakness. Obesity and smoking are common risk factors.
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.
Sliding hernias are more common than paraesophageal hernias. The incidence of hiatal hernia increases with age (most occur in people older than age 40), and prevalence is higher in women than in men (especially the paraesophageal type). Contributing factors include obesity and trauma. No racial predilection exists.
Typically, a paraesophageal hernia produces no symptoms; it’s usually an incidental finding during a barium swallow or when testing for occult blood. Because this type of hernia leaves the closing mechanism of the cardiac sphincter unchanged, it rarely causes acid reflux or reflux esophagitis. Symptoms result from displacement or stretching of the stomach and may include a feeling of fullness in the chest or pain resembling angina pectoris. Even if it produces no symptoms, this type of hernia needs surgical treatment because of the high risk of strangulation that can occur when a large portion of stomach becomes caught above the diaphragm.
A sliding hernia without an incompetent sphincter produces no reflux or symptoms and, consequently, doesn’t require treatment. When a sliding hernia causes symptoms, they are typical of gastric reflux, resulting from the incompetent lower esophageal sphincter (LES), and may include:
❑ Pyrosis (heartburn) occurs 1 to 4 hours after eating (especially overeating) 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, stomach distention, and spasm or altered motor activity. Chest pain usually occurs after meals or at bedtime and is aggravated by reclining, belching, and increased intra-abdominal pressure.
Other common symptoms reflect possible complications:
❑ 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 (usually occurs with paraesophageal hernia). Incarceration may lead to perforation of the gastric ulcer and strangulation and gangrene of the herniated portion of the stomach. It requires immediate surgery.
Diagnosis of hiatal hernia is based on typical clinical features and on the results of these laboratory studies and procedures:
❑ In barium study, hernia may appear as an outpouching containing barium at the lower end of the esophagus. Small hernias, however, are difficult to recognize. This study also shows diaphragmatic abnormalities.
❑ Endoscopy (esophagogastroduodenoscopy) and biopsy differentiate among 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 malignancy that otherwise may 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.
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 first because symptoms usually respond to it and because hiatal hernia tends to recur after surgery. Such therapy attempts to modify or reduce reflux by changing the quantity or quality of refluxed gastric contents, by strengthening the LES muscle pharmacologically, or by decreasing the amount of reflux through gravity. These measures include restricting any activity that raises intra-abdominal pressure (coughing, straining, or bending), giving antiemetics, avoiding constrictive clothing, modifying diet, giving stool softeners or laxatives to prevent straining at stool, and discouraging smoking because it stimulates gastric acid production.
Modifying the diet means eating small, frequent, bland meals at least 2 hours before lying down (no bedtime snack), eating slowly, and avoiding spicy foods, fruit juices, 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 6" (15 cm) reduces gastric reflux by gravity.
Drug therapy to strengthen cardiac sphincter tone may include a cholinergic agent or a GI stimulant to enhance smooth-muscle contraction, increase cardiac sphincter tone, and decrease reflux after eating.
Surgical repair is necessary when symptoms can’t be controlled medically or with the onset of complications, such as stricture, bleeding, pulmonary aspiration, strangulation, or incarceration. Surgery typically involves creating an artificial closing mechanism at the gastroesophageal junction to strengthen the LES’s barrier function. The surgeon may use an abdominal or a thoracic approach or he may repair the hernia by laparoscopic surgery, which allows for less dependence on a nasogastric (NG) tube and a shorter hospital stay.
To enhance compliance with treatment, teach the patient about this disorder. Explain 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).
❑ If surgery is scheduled, review preoperative and postoperative considerations with the patient.
❑ After surgery, carefully record intake and output, including NG tube and wound drainage.
❑ While the NG tube is in place, provide meticulous mouth and nose care, but don’t manipulate the tube. Give ice chips, if permitted, to moisten oral mucous membranes.
❑ If the surgeon used a thoracic approach, the patient may have chest tubes in place. Carefully observe chest tube drainage and the patient’s respiratory status, and perform pulmonary physiotherapy.
❑ Before discharge, tell the patient what foods he can eat, and recommend small, frequent meals. Warn against activities that cause increased intra-abdominal pressure, and advise a slow return to normal functions (within 6 to 8 weeks).
Review other book chapters online related to Hernia:
Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Professional Guide to Diseases (Eighth Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2005 ISBN: 1-58255-370-X 
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