Hiatal Hernia – Causes, Diagnosis & Treatment

According to the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), a hiatal hernia is a common disorder and is characterized by the protrusion of any abdominal structure other than the esophagus into the thoracic cavity through a widening of the hiatus of the diaphragm. Essentially, it is a condition in which the upper part of the stomach bulges through the opening of the diaphragm. The diaphragm has a fairly small opening through which the esophagus passes before connecting to the stomach. In this particular type of hernia, the stomach pushes up through that small opening and up into the chest.1 It is not always clear as to why this condition develops but may be attributed to weakened muscle tissue which allows the stomach to protrude through the diaphragm. Possible causes include age related changes, injury, genetics, or chronic pressure surrounding the muscles, such as coughing, vomiting, constant straining during bowel movements or exercising, pregnancy, or obesity. The prevalence of hiatal hernias is most common in obese women older than 50 years of age.

Currently there are four different types of hiatal hernias and be classified as: type I (sliding), type II (paraesophageal), type III (combined), type IV (giant paraesophageal). Hiatal hernias have been reported to affect approximately 10%-50% of the population and the symptoms and complication may differ among the different types. Type 1 conditions are the most common type of hiatal hernias, which account for more than 85%, while type II conditions are second most common.1 Type II conditions are at increased risk of complications due to gastroesophageal junction remaining in normal position, but part of the stomach squeezes through the hiatus. This can cause strangulation and the stomach can lose blood supply and result in damaged or ischemic tissue.3

A small hiatal hernia usually does not cause any significant health concerns and a portion of the time the patient does not realize they have one until they are evaluated for a different medical condition. Larger hiatal hernias pose a different situation. These hernias can allow food and acid to back up into the esophagus and essentially lead to heartburn, or in some cases cause significant damage to organs within the body. The most common symptom related to type I hiatal hernias is the coexistence of gastroesophageal reflux.1 Most patients who experience type II, III, and IV hiatal hernias are asymptomatic or have only vague, intermittent symptoms of substernal pain, fullness, nausea, and retching. GERD symptoms are less common with these types.1,2,3

Diagnosis

Hiatus hernia is usually not a diagnosis that is heavily pursued in and of itself, rather it is diagnosed incidentally by excluding other diagnoses or other conditions. This is due to the condition commonly presenting asymptomatically or in alignment with GERD symptoms. Having severe pain in the chest or stomach, severe nausea or vomiting, or severe constipation may be initial signs of the development of a hiatal hernia, along with the other common symptoms mentioned earlier. Due to possibility of severe complications surfacing from hiatal hernias, early diagnosis and subsequent treatment is vital, though not always the case1,3

If diagnosis of a hiatal hernia is warranted, there are many methods in order to confirm the presence of the condition. One method is a barium swallow. This is when a patient drinks a particular liquid that shows up on an X-ray, so the esophagus and stomach is visible. Another method is an endoscopy. This is when an endoscope is placed down a patients throat in order to see inside the esophagus and stomach. The last method for confirmatory diagnosis is called an esophageal manometry. This is when a tube is placed down a patients throat to check the pressure of the esophagus when swallowing. This method is used because a hiatal hernia is characterized by the separation of the crural diaphragm from the lower esophageal sphincter by a pressure trough. This test also helps identify intermittent herniation because it allows for extended observation. CT scans and plain chest X-rays may be helpful in identifying herniation, but cannot be used for definitive diagnosis.1,3

Treatment

As mentioned earlier, most patients who have a hiatal hernia present asymptomatically or with symptoms similar to GERD. Essentially, the treatment of hiatal hernia is similar to the management of GERD and should be reserved for individuals who have symptoms attributable to this disease. Surgery should be considered in patients whose symptoms are refractory and for those who develop complications due to the hernia, such as recurrent bleeding, ulcerations, strictures, obstruction, perforation, respiratory compromise or evidence of stomach strangulation.1,2,3

There are two types of surgeries that can be performed for the treatment of a hiatal hernia; open repair or laparoscopic repair. There is very little evidence to show which type of surgery technique is more efficacious. Both patients and providers need to address the pros and cons of both techniques, as well as patient preference. Also, a recent study showed that the use of non-absorbable mesh to support primary hiatal hernia repairs compared to using sutures alone resulted in similar rates of hernia recurrence and symptomatic outcomes.4 More studies need to be conducted in this patient population in order to make a clinical recommendation on this subject. If you want to get proper treatment about hernia then ask doctor online by visiting our website: https://justhealthexperts.com/

Natural and Non-Pharmacological Approaches

Most natural and non-pharmacological methods to treating a hiatal hernia are mostly lifestyle recommendations similar to those recommended in the management of GERD. For example, eating several smaller meals throughout the day rather than larger meals, avoid foods that trigger heartburn, avoid lying down after a meal or eating right before bedtime, maintain a healthy weight, smoking cessation, and elevating the head of your bed when sleeping. There are no natural or non-pharmacological approaches that cure the hernia and the underlying condition. To learn more about non-pharmacological approaches to aiding hernia, please visit the following link: natural approaches to aid hernia.

References

1. Dean, C., Etienne, D., Carpentier, B. et al. Hiatal hernias. Surg Radiol Anat 34, 291–299 (2012). https://doi.org/10.1007/s00276-011-0904-9
2. Hyun JJ, Bak YT. Clinical significance of hiatal hernia. Gut Liver. 2011;5(3):267‐277. doi:10.5009/gnl.2011.5.3.267
3. Kohn GP, Price RR, DeMeester SR, et al. Guidelines for the management of hiatal hernia. Surg Endosc. 2013;27(12):4409‐4428. doi:10.1007/s00464-013-3173-3
4. Oor JE, Roks DJ, Koetje JH, et al. Randomized clinical trial comparing laparoscopic hiatal hernia repair using sutures versus sutures reinforced with non-absorbable mesh. Surg Endosc. 2018;32(11):4579‐4589. doi:10.1007/s00464-018-6211-3

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