Hiatal hernia

Esophageal hernia, causes and treatment methods

Among the most serious ailments of the gastrointestinal tract, hiatal hernia occupies one of the leading positions. For successful treatment, it is necessary to carry out timely diagnosis and establish an accurate diagnosis.

The type and methods of rehabilitation are selected depending on the stage of the disease, taking into account the general condition of the patient. In combination with medication and surgical treatment, a variety of folk healing recipes are allowed. After completing the treatment course, a gentle diet is prescribed and sports activities are limited.

Causes

As the disease develops, expansions of various sizes appear in the opening of the diaphragm adjacent to the esophagus (hernial orifices), under some conditions allowing part of the esophagus or stomach to enter. The main causes of a hernia are: increased pressure inside the peritoneum, disorders of motility of the digestive canal in its esophageal part, as well as weakening of connective tissue ligaments.

Based on these reasons, the development of hiatal hernia is more typical for older people due to degenerative (involutional) changes in the tissues of the diaphragm and ligaments of the stomach and esophagus. This assumption is confirmed by the frequent presence of other hernias in patients with hiatal hernias (inguinal, femoral, etc.).

People with the following chronic diseases affecting connective tissue are also predisposed to the appearance of hiatal hernias:

Haemorrhoids.
Varicose veins
Flat feet.

Risk factors associated with increased intra-abdominal pressure include:

Obstructive pulmonary diseases.
Diseases accompanied by severe vomiting.
Pregnancy.
Hard physical work.
Abdominal injuries.
Severe flatulence, diarrhea (for example, with dysbacteriosis, infectious diseases of the gastrointestinal tract), frequent constipation.
Tumors of the abdominal wall.
Excess weight.

A hiatal hernia, formed due to disruption of the digestive tract, may be accompanied by the following conditions:

Ulcers of the esophagus and fundus of the stomach, sometimes of the duodenum.
Burns of the esophagus and stomach.
Reflux esophagitis.
Congenital shortening of the esophagus.
Chronic diseases of the spleen and pancreas.

In children, hiatal hernia is a rare phenomenon, in most cases associated with a congenital defect in the structure of the digestive tract or diaphragm (mediastinum).

Preparing for planned surgery

Before surgical treatment, the anesthesiologist/surgeon questions the patient in detail about his state of health, allergies, previous blood transfusions, etc. The patient is prescribed a series of tests that will allow him to evaluate the functions of the main organs: general blood and urine tests, biochemical analysis of venous blood, acid-base status, ECG.

If necessary, the patient’s condition is somewhat improved (pressure, heart activity, respiratory function are stabilized, etc.). Immediately before the operation, the intestines are cleansed (if there is no strangulation of the esophageal hernia), the bladder is catheterized and the necessary medications are administered.

Types of hiatal hernia

Comparative characteristics of the most common hiatal hernias:

Axial (sliding). Labile penetration of the entire abdominal organ or part of it into the food opening of the diaphragm. There are: esophageal (displacement of the abdominal part of the esophagus), cardiac (displacement of the esophagus, cardia of the stomach), cardio-fundal (displacement of the esophagus, cardia and fundus of the stomach). An axial hernia is considered a false hernia because there is no hernial sac.
Paraesophageal is a fixed displacement of the entire stomach or part of it through the food opening of the diaphragm next to the esophagus. There are: antral (displacement of the final part of the stomach) and fundal (displacement of the fundus of the stomach). It is considered a true hernia (a hernial sac is present) with a risk of strangulation.

With a long-term course of the pathology without treatment, the hernia can be differentiated as total or subtotal giant, which is no longer subject to conservative treatment.

Classification

Depending on the characteristics, doctors distinguish several types of pathologies. Each type requires individual treatment. An incorrect diagnosis leads to ineffective treatment and the appearance of concomitant diseases.

Sliding (wandering) hernia. The organs that make up the hernial protrusion move to different planes with each change in body position. In this case, a thin shell of connective tissue (hernial sac) is formed.
Paraesophageal (paraesophageal) hernia. The fundus of the stomach, a loop of intestine and the omentum move into the chest cavity.
A mixed hernia is characterized by symptoms of sliding and fixed pathology.
Congenital hernia. With congenital pathology of the short esophagus, the cardiac gastric section is located in the sternum. The gastric mucosa is located in the distal esophagus.
Fixed (axial) hernia. Displacement of the entire stomach or a separate part of it occurs along the vertical axis. Changing the position does not affect the size; the protrusion does not reduce on its own.

Based on the volume of protrusion, the hernia is divided into 3 degrees:

Hiatal hernia of the 1st degree - the stomach is slightly elevated, a small part of the lower esophagus enters the opening of the diaphragm;
Grade 2 is characterized by a slight displacement of the cardia relative to the diaphragm; the entire lower intestine is located in the sternum;
At stage 3, the cardia, lower esophagus, fundus and body of the stomach create a hernial protrusion.

Symptoms

Symptoms of a hiatal hernia in many cases are mild or absent altogether. This is explained by the small size of the protrusion.

Most often, the manifestation of pathology is observed in patients with large hernias. Signs of the disease include:

heartburn (occurs after eating);
pain in the sternum;
belching, feeling of fullness in the stomach;
prolonged hiccups;
difficulty passing food through the esophagus.

Symptoms of a hiatal hernia such as burning of the tongue (glossalgia), sour taste in the mouth, pain when bending or turning the body are often observed. Many patients complain of a feeling of a lump in the throat, increased salivation, and sudden coughing attacks, especially at night. The appearance of hernias can provoke pain in the heart area. Such signs make it difficult to diagnose the disease, as patients mistake the pathology for cardiac disorders.

Against the background of the formation of the disease, patients are diagnosed with anemia. The disease is a consequence of hidden internal bleeding in the esophagus and upper stomach.

A hiatal hernia (HH hernia), like other hiatal hernias, is a prolapse of the abdominal organs through the esophageal hiatus into the chest cavity.

Epidemiology

The prevalence of hiatal hernia increases with age and is somewhat more common in women.

Clinical picture

In most patients, a hiatal hernia is asymptomatic and is diagnosed as an incidental finding during examination performed for unrelated indications. However, when present, symptoms may include epigastric or chest pain, feeling of heaviness after eating, nausea and vomiting [3]. Sometimes hernias are considered synonymous with gastroesophageal reflux disease, but there is no correlation between the two entities.

Pathology

The most common content of this type of hernia is the stomach. There are two main types (although they can coexist):

sliding hernia UNDER (> 90%)
paraesophageal hernia POD (<10%)

Sliding hiatal hernia

It is the most common type of hernia (~90%). In this case, the esophagogastric junction is displaced ~2 cm above the esophageal opening of the diaphragm, and the opening itself often abnormally widens to 3-4 cm (the upper limit of normal is 1.5 cm). The fundus of the stomach may also move above the diaphragm and form an additional shadow behind the shadow of the heart. The presence of fluid levels indicates the diagnosis. Small sliding hernias usually decrease in size in an upright position.

Paraesophageal hiatal hernia

Paraesophageal hernia is less common than sliding hernia. The esophagogastric junction maintains its normal position below the diaphragm while part of the stomach prolapses through the esophagus.

Diagnostics

Radiography

Shadow with gas-liquid level behind heart shadow

X-ray

The presence of relief of gastric folds in the supradiaphragmatic region
Tortuosity of the esophagus with an eccentric position of the gastroesophageal junction

CT scan

local accumulation of adipose tissue in the middle part of the mediastinum, the omentum prolapses through the diaphragmatic-esophageal ligament
there may be an increase in the amount of adipose tissue in the distal segment of the esophagus

paraesophageal hernia

the stomach with its contents is visualized above the diaphragm

hernial contents are located next to the esophagus

dilatation of the esophageal opening

an increase in the distance between the legs and the walls of the esophagus by more than 15 mm

Differential diagnosis

On a chest x-ray in AP projection:

lung abscess
pleural empyema
thoracic esophageal diverticulum
postoperative changes: esophagectomy with gastric tightening procedure

In the presence of injury, a diaphragm rupture must be added to the differential series.

Diagnostics

Due to the fact that a hernia can occur in combination with many other diseases, the diagnosis of this disease can be complicated due to the similarity of symptoms.

To diagnose a hernia, doctors use the following methods to identify it:

An X-ray machine is designed to examine the internal cavity of the body. Since the body has parts of different densities, they appear differently on an x-ray. The denser parts are the bones, which are clearly visible in the picture. To identify organ pathologies, it is necessary to administer a special contrast agent. “Illuminated” internal organs make it possible to determine the presence of pathologies;
To determine the quality of esophageal motility, intraesophageal manometry is used. Food entering the esophagus must be delivered to the digestive organs through muscle contractions. This procedure helps to determine the dysfunction of the muscular system, determine the quality of pressure during contractions and observe the amplitude of movements. To do this, a probe with sensors that detect pressure is inserted through the nasopharynx.

Surgery for hiatal hernia

There are different surgical techniques:

Operation Belsey. Performed if the hernia is large. It is performed through an incision in the sixth intercostal space, on the left side of the sternum. The essence of the operation is that the lower part of the esophagus and esophageal sphincter is attached to the diaphragm.
Nissen fundoplication. One of the most common operations. It is performed using laparoscopic technique or the open method. In this case, the upper third of the stomach is wrapped around the esophagus. This “cuff” prevents stomach contents from entering the esophagus.
Allison's technique. The incision is made in the seventh and eighth intercostal space. In this case, the hernial orifice is sutured.
Gastrocardiopexy. It is performed through an incision above the navel, along the midline of the abdomen. The upper third of the stomach and esophagus are sutured to the subdiaragmal structures.

The goal of surgery is to restore the anatomical structure of the esophagus and create an anti-reflux mechanism that will prevent the reflux of gastric contents.

What to do at home?

Rules for the behavior of a patient with a diaphragmatic hernia should exclude exposure to factors that cause an increase in intra-abdominal pressure in order to prevent further displacement of organs into the chest cavity and progression of the disease:

Take food in fractional portions every few hours;
Before and after meals, it is recommended to drink a teaspoon of unrefined vegetable oil;
Patients are advised to follow a special diet that excludes foods that cause intestinal irritation;
You should not tighten your belt too tightly or wear clothes that squeeze your stomach - this creates additional pressure in the abdominal cavity;
Avoid bending the body forward, sudden changes in body position - this can cause pain in the sternum and heartburn;
Normalize stool - constipation and diarrhea increase intra-abdominal pressure and contribute to the formation of a hiatal hernia.
Avoid heavy physical activity, but at the same time regularly perform physical therapy exercises that strengthen the muscle corset and restore the tone of the diaphragm;
Pain and heartburn with a diaphragmatic hernia intensify at night and become more pronounced when the body moves to a horizontal position, so before resting it is necessary to abstain from food - the last dose is at least three hours before bedtime.

Alkaline mineral waters, such as Borjomi, help to remove symptoms of heartburn and restore the acid-base balance in the esophagus. A medicine used to neutralize gastric juice in case of diaphragmatic hernia is Almagel. It is drunk on an empty stomach, 20-30 minutes before meals, two teaspoons at a time. Regular use of the drug allows you to neutralize the negative effects of gastric juice on the walls of the esophagus and prevent the development of complications of a diaphragmatic hernia.

Treatment and prevention of hernia

Since the clinical picture of the disease in the vast majority of cases is determined by reflux of gastric contents, the treatment prescribed is the same as for reflux esophagitis.

In severe cases and if drug therapy is unsuccessful, surgical treatment is performed (suturing the hernial orifice, strengthening the esophageal-diaphragmatic ligament, various methods of fixing the stomach in the abdominal cavity, fundoplication). After completing the main course of treatment, all patients must be registered with a gastroenterologist.

How to treat a hiatal hernia without surgery?

To eliminate the clinical manifestations of all concomitant diseases of the digestive system (gastritis, gastroesophageal reflux, ulcers, dyskinesia and erosions), an individual program of complex drug therapy is developed for each patient, including the use of:

Proton pump inhibitors (esomeprazole, omeprazole, pantoprazole).
Antacids (represented by Almagel, Maalox and Gastal).
Prokinetics that improve the condition of the mucous membranes of the esophagus (ganatone, motilium, trimebutine, motilac).
H2-antihistamines (most often ranitidine).
B vitamins that can speed up the restoration of gastric structures.

To relieve pain, patients can be prescribed non-steroidal anti-inflammatory drugs (represented by paracetamol, ibuprofen, nurofen). In some cases, taking these medications can provoke an increase in clinical manifestations characteristic of gastroenterological diseases.

To enhance the effectiveness of drug treatment, patients are recommended to:

adhere to a gentle diet;
start normalizing your weight;
during night sleep, take a semi-sitting position (thanks to the raised head of the bed);
avoid any physical activity.

Indications for the need for surgical intervention are the presence of:

complete failure of drug treatment;
complicated forms of diaphragmatic hernia;
precancerous (also called dysplastic) changes in the mucous membranes of the esophagus.

There are quite a large number of options for surgical treatment of diaphragmatic hernias.

Gymnastics

For hiatal hernia, physical therapy is recommended. The following exercises help a lot:

Lie on your side and rest your head on the cushion. Inhale deeply and inflate your stomach as much as possible, then exhale slowly and relax. Repeat 4-5 times.
Get on your knees, straighten your back, inhale and slowly bend to the right, exhale and return to the starting position, repeat the exercise 6-7 times.
Lie on your back. Breathing is even and calm. Slowly turn to your left and then to your right side, trying not to lose your breath.

Nutrition rules and diet

In addition to taking medications for hiatal hernia, treatment involves prescribing a diet, adjusting the daily routine, and traditional medicine recipes are used as an additional measure.

There are certain diet rules that are recommended to be followed to more quickly eliminate negative symptoms:

Meals should be small, evening meals should be completed several hours before bedtime.
A specialist can prescribe mineral water; preference is given to alkaline waters; they are consumed 30 minutes before meals in a single volume of 100 ml.
The possibility of overeating should be excluded, for which daily calorie counting is carried out - it should not exceed 1800-2000 kilocalories.

A patient with hiatal hernia should avoid using:

Any fatty, fried and spicy foods.
Fatty products made from cow's milk.
Butter and vegetable oil.
Coffee, chocolate and cocoa.
Onions (both green and onions) and garlic.
Coarse fiber found in whole nuts and grains, hard raw fruits and vegetables, bran.
Dishes (including drinks and sauces) made from tomatoes.
Pickles.
Crackers and chips.
Ice cream.
Mustard, ketchup and vinegar.
Any carbonated drinks.

The diet of a patient with hiatal hernia requires the presence of:

Porridges prepared with skim milk or water.
Dishes made from low-fat goat and cow milk.
Lean meat and fish.
Baked or mashed apples.
Fresh bananas.
Baked potatoes and carrots.
Egg whites.
Green peas and green beans.
Steamed broccoli.
Soft cookies.
Baked goods made from rice flour.
Marmalade, marshmallows, jelly and marshmallows.

Since a hiatal hernia occurs against the background of unbearable heartburn, it is necessary to exclude foods that can provoke its occurrence from the patient’s diet. Equally undesirable are drinks and dishes, the consumption of which leads to bloating.

Traditional methods of treatment

It is worth learning from traditional medicine how to treat a hernia only as an additional method of improving well-being, if the doctor who determined the tactics of treatment with diet and medication approves the auxiliary intervention.

A good addition to your diet would be to use mild, anti-inflammatory chamomile or lightly brewed green tea. When choosing infusions and herbs, you should look for an option that will reduce stomach acidity, heartburn and abdominal discomfort. Often recommended ginger and lemon teas for hernia and other gastroenterological diseases are contraindicated.

Operation

The purpose of the operation is to restore the anatomical position and normal function of the cardia. The basic principle is to eliminate the hernial orifice and perform antireflux surgery. This is done by mobilizing and lowering the esophageal-gastric junction into the abdominal cavity, narrowing the esophageal opening of the diaphragm and performing one of the types of fundoplication, which allows you to restore the lower esophageal sphincter, the high pressure zone in it and the angle of His.

The most common is the operation by Nissen, who proposed a 360° fundoplication for the treatment of a hiatal hernia complicated by esophagitis. It consists of forming a circular cuff from the anterior and posterior walls of the fundus of the stomach, enveloping the mobilized abdominal section of the esophagus, in which a 30-32F1 probe is installed. The edges of the stomach are sutured together with the wall of the esophagus. The width of the cuff is at least 2.5-3 cm. If the hernial opening is wide (more than 3.5 cm), the legs of the diaphragm are sutured together behind or in front of the esophagus (posterior or anterior crurorrhaphy) to the normal size of the POD. When the POD diameter is more than 5 cm, to prevent recurrence of the hernia, it is advisable to strengthen the crurorrhaphy with a mesh prosthesis made of non-absorbable synthetic material.
Fundoplication according to Nissen-Rossetti also involves a 360° fundoplication with the difference that the gastric cuff is not fixed to the diaphragm (prevention of hiccups and pain during breathing movements), but 1-2 sutures are placed between the esophagus and the gastric cuff on the side opposite from the sutures of the cuff itself (prevention of cuff expansion in the fundus of the stomach). The disadvantage of the Nissen and Nissen-Rosetti operations is the twisting of the esophagus along the axis when the fundus of the stomach is passed under it. This can be avoided by modifying the Nissen operation, in which the first short arteries of the stomach, the posterior (not covered by the peritoneum) wall of the cardia are mobilized, and the anterior and posterior walls of the fundus of the stomach are involved in creating the cuff.
Toupet fundoplication involves the formation of a symmetrical cuff from the anterior and posterior walls of the fundus of the stomach, enveloping the esophagus at 240-270°, leaving its anterior-right surface free (localization of the left vagus nerve). Used for small stomach fundus. Many authors prefer this method of fundoplication due to the lower incidence of dysphagia in the early postoperative period (compared to the Nissen procedure). This advantage is offset in the future due to a greater number of relapses of reflux disease.
Fundoplication according to Dor. It also involves partial fundoplication, in which the anterior wall of the fundus of the stomach is placed in front of the abdominal esophagus, fixing it to the right wall of the esophagus. This operation is ineffective; it is rarely used as a forced measure when it is impossible to fully mobilize the esophagogastric junction and perform other types of fundoplication.
The Cuschieri operation (1991) is the creation of an acute angle of His using the round ligament of the liver, which, after partial mobilization from the navel, is carried out with the free end under the abdominal segment of the esophagus, pulling it to the right and anteriorly (an acute angle of His is formed). Rarely used due to low efficiency.

For hernias combined with pronounced shortening of the esophagus (congenital or due to esophagitis), the Collis-Nissen operation gives the best results. The operation consists of lengthening the abdominal esophagus due to the lesser curvature of the stomach, followed by gastrofundorraphy (enveloping the newly created esophageal tube from the lesser curvature with the walls of the fundus of the stomach according to the Nissen fundoplication type).

Complications

The disease sometimes leads to a number of complications, and this will not depend on the classifications and causes of its origin. This hernia may be accompanied by esophageal bleeding, transition of the esophagus into the so-called “hernial sac” or gastric mucosa, inflammation of the gastric mucosa, shortening of the esophagus, strangulation of the hernia (here surgical intervention will be inevitable).

A strangulated esophageal hernia is characterized by increased pain, bloating and severe tension of the abdominal walls, and the appearance of prolonged, uncontrollable vomiting. In such a case, emergency suturing of the diaphragmatic opening is performed to a normal size after repositioning the esophagus into the abdominal cavity.

Postoperative period

In cases of uncomplicated course of the disease and successful laparoscopic surgery, postoperative management of patients does not go beyond standard measures (pain relief according to indications, antibiotic prophylaxis during surgery and on the 1st day after it, nutrition with liquid food from the 1st day, removal of safety drainage through 12-24 hours). The duration of hospitalization is on average from 2 to 5 days.

If complications develop, appropriate therapy is provided. To evaluate the results of treatment, it is recommended after 3-6 months. perform gastric X-ray, endoscopy and pH monitoring.

Treatment methods

How to treat a hiatal hernia is decided jointly by a gastroenterologist and a abdominal surgeon. To draw up the correct method of therapy, the type and characteristics of the pathology are important (sliding or fixed hernia, whether there is any infringement of organs).

The main treatment takes place at home and includes four methods:

diet,
taking medications,
exercise therapy,
traditional methods.

For the following complications, surgical intervention is resorted to:

strangulated hernia;
bleeding;
introduction of one hernia organ into another;
A large number of organs have entered the chest cavity, and they are compressing the heart.

In other cases, the operation is carried out as planned (the duration is not limited, but it is recommended within several weeks) in a specialized department of “thoracic surgery”.

Forecast

In case of untimely diagnosis and incorrect treatment tactics, a hiatal hernia can provoke the appearance of:

Peptic ulcers of the esophagus and stomach.
Reflex angina.
Perforation of the esophageal tube.
Various forms (erosive, catarrhal, ulcerative) esophagitis.
Cicatricial stenosis of the esophagus.

For 30% of patients, untreated hiatal hernia can result in esophageal cancer. With adequate and timely treatment of diaphragmatic hernias, in 80% of cases the condition of patients improves significantly. Stage I diseases are completely cured. Cases of relapse are extremely rare.

Prevention

Preventive measures against hiatus hernia include following simple rules:

compliance with similar recommendations indicated for conservative treatment;
timely elimination of diseases or disorders that can lead to such an illness;
taking regular walks, especially after eating food;
undergo regular preventive examinations, in particular x-rays.

The prognosis of a hiatal hernia is directly related to the development of complications. After surgery, relapses of the disease are extremely rare. However, patients will need to be followed by a gastroenterologist for the rest of their lives.