A
hiatus hernia or
hiatal hernia is the protrusion (or herniation) of the upper part of the
stomachIn most mammals, the stomach is a hollow, muscular organ of the gastrointestinal tract , between the esophagus and the small intestine. It is involved in the second phase of digestion, following mastication . The word stomach is derived from the Latin stomachus, which derives from the Greek word...
into the
thoraxThe thorax is a division of an animal's body that lies between the head and the abdomen.In mammals, the thorax is the region of the body formed by the sternum, the thoracic vertebrae and the ribs. It extends from the neck to the diaphragm, and does not include the upper limbs. The heart and the...
through a tear or weakness in the diaphragm.
The symptoms include acid reflux, and pain, similar to heartburn, in the chest, and upper stomach.
In most patients, hiatus hernias cause no symptoms. Sometimes patients experience
heartburnHeartburn or pyrosis is a painful and burning sensation in the esophagus, just behind the breastbone usually associated with regurgitation of gastric acid. The pain often rises in the chest and may radiate to the neck, throat, or angle of the jaw...
and
regurgitationRegurgitation is the controlled flow of stomach contents back into the esophagus and mouth.Regurgitation is used by a number of species to feed their young...
, when stomach acid refluxes back into the
esophagusThe esophagus or oesophagus , sometimes known as the gullet, is an organ in vertebrates which consists of a muscular tube through which food passes from the pharynx to the stomach. The word esophagus is derived from the Latin œsophagus, which derives from the Greek word oisophagos , lit...
.
The following are risk factors for having a hiatus hernia.
- Increased pressure within the abdomen
In vertebrates such as mammals the abdomen constitutes the part of the body between the thorax and pelvis. The region enclosed by the abdomen is termed the abdominal cavity...
caused by:
- Heavy lifting or bending over
- Frequent or hard coughing
- Hard sneezing
- Pregnancy
Pregnancy is the carrying of one or more offspring, known as a fetus or embryo, inside the uterus of a female. In a pregnancy, there can be multiple gestations, as in the case of twins or triplets. Human pregnancy is the most studied of all mammalian pregnancies. Obstetrics is the surgical field...
and delivery
- Violent vomiting
Vomiting is the forceful expulsion of the contents of one's stomach through the mouth and sometimes the nose. Undesired vomiting may result from many causes, ranging from gastritis or poisoning to brain tumors, or elevated intracranial pressure...
- Straining with constipation
Constipation, costiveness, or irregularity is a condition of the digestive system in which a person experiences hard feces that are difficult to expel. This usually happens because the colon absorbs too much water from the food...
- Obesity
Obesity is a medical condition in which excess body fat has accumulated to the extent that it may have an adverse effect on health, leading to reduced life expectancy and/or increased health problems...
(extra weight pushes down on the abdomen increasing the pressure)
- Use of the sitting position for defecation
Defecation is the final act of digestion by which organisms eliminate solid, semisolid or liquid waste material from the digestive tract via the anus. Humans usually defecate from three times a week, up to three times a day...
(See epidemiology below)
- Heredity
Heredity is the passing of traits to offspring . This is the process by which an offspring cell or organism acquires or becomes predisposed to the characteristics of its parent cell or organism. Through heredity, variations exhibited by individuals can accumulate and cause a species to evolve...
- Smoking
Tobacco smoking is the practice where tobacco is burned and the vapors either tasted or inhaled. The practice began as early as 5000–3000 BC. Many civilizations burnt incense during religious rituals, which was later adopted for pleasure or as a social tool. Tobacco was introduced to the old world...
- Drug use
Drugs can be used in many different ways, as detailed below.-Medication:People can use drugs to relieve pain or discomfort or to cure or prevent disease.-Recreational drug use:...
, such as cocaine.
- Stress
Stress is a biological term for the consequences of the failure of a human or animal to respond appropriately to emotional or physical threats to the organism, whether actual or imagined....
- Diaphragm weakness
The diagnosis of a hiatus hernia is typically made through an
upper GI seriesUpper GI series, also upper gastrointestinal tract radiography, is a radiologic examination of the upper gastrointestinal tract. It consists of a series of X-ray images of the esophagus, stomach and duodenum...
or endoscopy.
There are two major kinds of hiatus hernia:
- The most common (95%) is the sliding hiatus hernia, where the gastroesophageal junction moves above the diaphragm together with some of the stomach.
- The second kind is rolling (or paraesophageal) hiatus hernia, when a part of the stomach herniates through the esophageal hiatus
In human anatomy, the esophageal hiatus is a hole in the diaphragm through which the esophagus passes. It is located in the right crus of the diaphragm.It is located approximately at level of the tenth thoracic vertebra ....
and lies beside the esophagus, without movement of the gastroesophageal junction.
A
hiatus hernia or
hiatal hernia is the protrusion (or herniation) of the upper part of the
stomachIn most mammals, the stomach is a hollow, muscular organ of the gastrointestinal tract , between the esophagus and the small intestine. It is involved in the second phase of digestion, following mastication . The word stomach is derived from the Latin stomachus, which derives from the Greek word...
into the
thoraxThe thorax is a division of an animal's body that lies between the head and the abdomen.In mammals, the thorax is the region of the body formed by the sternum, the thoracic vertebrae and the ribs. It extends from the neck to the diaphragm, and does not include the upper limbs. The heart and the...
through a tear or weakness in the diaphragm.
Symptoms
The symptoms include acid reflux, and pain, similar to heartburn, in the chest, and upper stomach.
In most patients, hiatus hernias cause no symptoms. Sometimes patients experience
heartburnHeartburn or pyrosis is a painful and burning sensation in the esophagus, just behind the breastbone usually associated with regurgitation of gastric acid. The pain often rises in the chest and may radiate to the neck, throat, or angle of the jaw...
and
regurgitationRegurgitation is the controlled flow of stomach contents back into the esophagus and mouth.Regurgitation is used by a number of species to feed their young...
, when stomach acid refluxes back into the
esophagusThe esophagus or oesophagus , sometimes known as the gullet, is an organ in vertebrates which consists of a muscular tube through which food passes from the pharynx to the stomach. The word esophagus is derived from the Latin œsophagus, which derives from the Greek word oisophagos , lit...
.
Risk factors
The following are risk factors for having a hiatus hernia.
- Increased pressure within the abdomen
In vertebrates such as mammals the abdomen constitutes the part of the body between the thorax and pelvis. The region enclosed by the abdomen is termed the abdominal cavity...
caused by:
- Heavy lifting or bending over
- Frequent or hard coughing
- Hard sneezing
- Pregnancy
Pregnancy is the carrying of one or more offspring, known as a fetus or embryo, inside the uterus of a female. In a pregnancy, there can be multiple gestations, as in the case of twins or triplets. Human pregnancy is the most studied of all mammalian pregnancies. Obstetrics is the surgical field...
and delivery
- Violent vomiting
Vomiting is the forceful expulsion of the contents of one's stomach through the mouth and sometimes the nose. Undesired vomiting may result from many causes, ranging from gastritis or poisoning to brain tumors, or elevated intracranial pressure...
- Straining with constipation
Constipation, costiveness, or irregularity is a condition of the digestive system in which a person experiences hard feces that are difficult to expel. This usually happens because the colon absorbs too much water from the food...
- Obesity
Obesity is a medical condition in which excess body fat has accumulated to the extent that it may have an adverse effect on health, leading to reduced life expectancy and/or increased health problems...
(extra weight pushes down on the abdomen increasing the pressure)
- Use of the sitting position for defecation
Defecation is the final act of digestion by which organisms eliminate solid, semisolid or liquid waste material from the digestive tract via the anus. Humans usually defecate from three times a week, up to three times a day...
(See epidemiology below)
- Heredity
Heredity is the passing of traits to offspring . This is the process by which an offspring cell or organism acquires or becomes predisposed to the characteristics of its parent cell or organism. Through heredity, variations exhibited by individuals can accumulate and cause a species to evolve...
- Smoking
Tobacco smoking is the practice where tobacco is burned and the vapors either tasted or inhaled. The practice began as early as 5000–3000 BC. Many civilizations burnt incense during religious rituals, which was later adopted for pleasure or as a social tool. Tobacco was introduced to the old world...
- Drug use
Drugs can be used in many different ways, as detailed below.-Medication:People can use drugs to relieve pain or discomfort or to cure or prevent disease.-Recreational drug use:...
, such as cocaine.
- Stress
Stress is a biological term for the consequences of the failure of a human or animal to respond appropriately to emotional or physical threats to the organism, whether actual or imagined....
- Diaphragm weakness
Diagnosis
The diagnosis of a hiatus hernia is typically made through an
upper GI seriesUpper GI series, also upper gastrointestinal tract radiography, is a radiologic examination of the upper gastrointestinal tract. It consists of a series of X-ray images of the esophagus, stomach and duodenum...
or endoscopy.
Types
There are two major kinds of hiatus hernia:
- The most common (95%) is the sliding hiatus hernia, where the gastroesophageal junction moves above the diaphragm together with some of the stomach.
- The second kind is rolling (or paraesophageal) hiatus hernia, when a part of the stomach herniates through the esophageal hiatus
In human anatomy, the esophageal hiatus is a hole in the diaphragm through which the esophagus passes. It is located in the right crus of the diaphragm.It is located approximately at level of the tenth thoracic vertebra ....
and lies beside the esophagus, without movement of the gastroesophageal junction. It is about 5% as common as the first kind.
A third kind is also sometimes described, and is a combination of the first and second kinds.
Treatment
In most cases, sufferers experience no discomfort and no treatment is required. However, when the hiatal hernia is large, or is of the paraesophageal type, it is likely to cause
esophageal strictureBenign esophageal stricture is a narrowing of the esophagus that causes swallowing difficulties. It can be caused by or associated with gastroesophageal reflux disease, esophagitis , dysfunctional lower esophageal sphincter, disordered motility, or a hiatal hernia.-Diagnosis:It can be diagnosed...
and discomfort. Symptomatic patients should elevate the head of their beds and avoid lying down directly after meals until treatment is rendered. If the condition has been brought on by stress,
stress reduction techniquesStress management is the amelioration of stress, especially chronic stress.-Historical foundations:Walter Cannon and Hans Selye used animal studies to establish the earliest scientific basis for the study of stress...
may be prescribed, or if overweight,
weight lossWeight loss, in the context of medicine, health or physical fitness, is a reduction of the total body mass, due to a mean loss of fluid, body fat or adipose tissue and/or lean mass, namely bone mineral deposits, muscle, tendon and other connective tissue...
may be indicated. Medications that reduce the lower esophageal sphincter (or LES) pressure should be avoided. Antisecretory drugs like proton pump inhibitors and H
2 receptor blockers can be used to reduce acid secretion.
Where hernia symptoms are severe and chronic acid reflux is involved,
surgerySurgery is a medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, to help improve bodily function or appearance, or sometimes for some other reason...
is sometimes recommended, as chronic reflux can severely injure the
esophagusThe esophagus or oesophagus , sometimes known as the gullet, is an organ in vertebrates which consists of a muscular tube through which food passes from the pharynx to the stomach. The word esophagus is derived from the Latin œsophagus, which derives from the Greek word oisophagos , lit...
and even lead to
esophageal cancerEsophageal cancer is malignancy of the esophagus. There are various subtypes, primarily squamous cell cancer and adenocarcinoma. Squamous cell cancer arises from the cells that line the upper part of the esophagus. Adenocarcinoma arises from glandular cells that are present at the junction of the...
.
The surgical procedure used is called
Nissen fundoplicationNissen fundoplication is a surgical procedure to treat gastroesophageal reflux disease and hiatus hernia. In GERD it is usually performed when medical therapy has failed, but with paraesophageal hiatus hernia, it is the first-line procedure...
. In fundoplication, the gastric fundus (upper part) of the stomach is wrapped, or plicated, around the inferior part of the esophagus, preventing herniation of the stomach through the hiatus in the diaphragm and the reflux of
gastric acidGastric acid is a secretion produced in the stomach. It is one of the main ditotonic solutions secreted, together with several enzymes and intrinsic factors...
. The procedure is now commonly performed
laparoscopicallyLaparoscopic surgery, also called minimally invasive surgery , bandaid surgery, keyhole surgery is a modern surgical technique in which operations in the abdomen are performed through small incisions as compared to larger incisions needed in traditional surgical procedures.Practicioners of "open"...
. With proper patient selection, laparoscopic fundoplication has low complication rates and a quick recovery.
Complications include gas bloat syndrome,
dysphagiaDysphagia is the medical term for the symptom of difficulty in swallowing. Although classified under "symptoms and signs" in ICD-10, the term is sometimes used as a condition in its own right. Sufferers are sometimes unaware of their dysphagia....
(trouble swallowing),
dumping syndromeGastric dumping syndrome, or rapid gastric emptying, happens when the upper end of the small intestine, the jejunum, expands too quickly due to the presence of hyperosmolar food from the stomach. "Early" dumping begins concurrently or immediately succeeding a meal. Symptoms of early dumping include...
, excessive scarring, and rarely,
achalasiaAchalasia, also known as esophageal achalasia, achalasia cardiae, cardiospasm, and esophageal aperistalsis, is an esophageal motility disorder: The smooth muscle layer of the esophagus loses normal peristalsis , and the lower esophageal sphincter fails to relax properly in response to...
. The procedure sometimes fails over time, requiring a second surgery to make repairs.
Complications
A hiatus hernia
per se does not cause any symptoms. The condition promotes reflux of gastric contents (
via its direct and indirect actions on the anti-reflux mechanism) and thus is associated with
gastroesophageal reflux diseaseGastroesophageal reflux disease ', gastro-oesophageal reflux disease ', gastric reflux disease, or acid reflux disease is defined as chronic symptoms or mucosal damage produced by the abnormal reflux inthe esophagus....
(GERD). In this way a hiatus hernia is associated with all the potential consequences of GERD -
heartburnHeartburn or pyrosis is a painful and burning sensation in the esophagus, just behind the breastbone usually associated with regurgitation of gastric acid. The pain often rises in the chest and may radiate to the neck, throat, or angle of the jaw...
,
esophagitis- Causes :* The most common cause is gastroesophageal reflux disease . If caused by GERD, the diseases is also called reflux esophagitis....
,
Barrett's esophagusBarrett's esophagus refers to an abnormal change in the cells of the lower end of the esophagus thought to be caused by damage from chronic acid exposure, or reflux esophagitis...
and
esophageal cancerEsophageal cancer is malignancy of the esophagus. There are various subtypes, primarily squamous cell cancer and adenocarcinoma. Squamous cell cancer arises from the cells that line the upper part of the esophagus. Adenocarcinoma arises from glandular cells that are present at the junction of the...
. However the risk attributable to the hiatus hernia is difficult to quantify, and at most is low.
Besides discomfort from GERD and dysphagia, hiatal hernias can have severe consequences for patients if not treated. While sliding hernias are primarily associated with gastroesophageal acid reflux, rolling hernias can strangulate a portion of the stomach above the diaphragm. This strangulation can result in esophageal or GI tract obstruction and the tissue can even become ischemic and
necroseNecrosis is the premature death of cells and living tissue. Necrosis is caused by external factors, such as infection, toxins , or trauma. This is in contrast to apoptosis, which is a naturally occurring cause of cellular death...
.
Another severe complication, although very rare, is a large herniation that can restrict the inflation of a
lungThe lung or pulmonary system is the essential respiration organ in air-breathing animals, including most tetrapods, a few fish and a few snails. In mammals and the more complex life forms, the two lungs are located in the chest on either side of the heart...
, causing pain and breathing problems.
Epidemiology
Hiatus hernias affect anywhere from 1 to 20% of the population. Of these, 9% are symptomatic, depending on the competence of the lower esophageal sphincter (LES). 95% of these are "sliding" hiatus hernias, in which the LES protrudes above the diaphragm along with the stomach, and only 5% are the "rolling" type (paraesophageal), in which the LES remains stationary but the stomach protrudes above the diaphragm. People of all ages can get this condition, but it is more common in older people.
According to Dr. Denis Burkitt, "Hiatus hernia has its maximum prevalence in economically developed communities in North America and Western Europe....In contrast the disease is rare in situations typified by rural African communities." Burkitt attributes the disease to insufficient dietary fiber and the use of the unnatural sitting position for defecation. Both factors create the need for straining at stool, increasing intraabdominal pressure and pushing the stomach through the esophageal hiatus
in the diaphragm.
External links