What is a hiatal hernia. How are hiatal hernias classified. What causes hiatal hernias. What are the symptoms of hiatal hernias. How was this rare right-sided hiatal hernia discovered. What made this hiatal hernia case unique. How does this case contribute to medical knowledge.

Understanding Hiatal Hernias: Types, Causes, and Symptoms

A hiatal hernia occurs when abdominal contents, typically the stomach, protrude through the esophageal hiatus into the mediastinum. This opening in the diaphragm, located at the T10 vertebral level, normally allows the esophagus and vagal trunks to pass into the abdominal cavity.

Types of Hiatal Hernias

Hiatal hernias are classified into four types:

• Type I (Sliding Hiatal Hernia): Accounts for 95% of cases. The gastroesophageal junction (GEJ) is displaced superiorly, with portions of the gastric cardia herniating into the posterior mediastinum.
• Type II: The GEJ remains in its normal position, but the gastric fundus herniates.
• Type III: Combines features of Types I and II, with a superiorly displaced GEJ and large stomach herniation.
• Type IV: Similar to Type III, but includes herniation of other organs such as the colon, spleen, pancreas, or small intestines.

Causes of Hiatal Hernias

The exact causes of paraesophageal hernias are not fully understood. However, factors that may contribute include:

• Increased age
• Elevated intra-abdominal pressure
• Laxity of the external sphincter of the esophagogastric junction

Symptoms and Complications

Hiatal hernias can present with various symptoms, ranging from acute to chronic:

• Acute symptoms: Obstructions, which may lead to bleeding, ischemia, perforation, and sepsis
• Chronic symptoms: Dysphagia, nausea, vomiting, regurgitation, heartburn, ulcers, anemia, poor emptying, and shortness of breath

It’s important to note that some patients with hiatal hernias may be asymptomatic.

A Rare Case: Massive Right-Sided Hiatal Hernia

During a routine cadaver dissection for first-year medical students, an unusual anatomical variant was discovered in an 84-year-old female cadaver. This case presented a massive Type IV hiatal hernia with a unique right-sided displacement.

Unique Features of the Case

The hernia exhibited several noteworthy characteristics:

• 100% of the stomach was herniated
• The pyloric sphincter was included in the herniation
• Portions of the greater and lesser omentums were also displaced
• The herniation occurred on the right side of the thoracic cavity

This case is particularly rare due to two factors: the size of the esophageal hiatus and the right-sided displacement of the hernia.

Significance of the Hiatal Surface Area (HSA)

The hiatal surface area (HSA) in this case was calculated to be almost three times the established average HSA in normal patients. This significant enlargement of the esophageal hiatus allowed for the massive herniation of abdominal contents into the thoracic cavity.

Implications of Enlarged HSA

An enlarged HSA can have several implications:

• Increased risk of herniation
• Potential for more severe symptoms
• Challenges in surgical repair
• Higher likelihood of recurrence after repair

Right-Sided Paraesophageal Hernias: A Rare Occurrence

The majority of reported paraesophageal hernias (PEH) are left-sided. Right-sided PEH are rarely mentioned in the literature, making this case particularly noteworthy.

Why Are Right-Sided PEH Rare?

Several factors may contribute to the rarity of right-sided PEH:

• Anatomical positioning of the esophagus
• Natural leftward displacement of the stomach
• Presence of the liver on the right side

Clinical Implications of Right-Sided Hiatal Hernias

The unusual presentation of a right-sided hiatal hernia can have significant clinical implications:

Diagnostic Challenges

Right-sided hiatal hernias may pose diagnostic challenges due to their rarity. Healthcare providers might not immediately consider this possibility when evaluating patients with gastrointestinal or respiratory symptoms.

Surgical Considerations

The surgical approach for repairing a right-sided hiatal hernia may differ from the standard techniques used for more common left-sided hernias. Surgeons need to be aware of this possibility and adapt their approach accordingly.

Potential Complications

Right-sided hiatal hernias may lead to unique complications due to their anatomical position. These could include:

• Compression of right-sided thoracic structures
• Interference with liver function
• Altered dynamics of the right hemidiaphragm

The Importance of Cadaveric Studies in Medical Education

This case highlights the invaluable role of cadaveric studies in medical education and research. The discovery of this rare anatomical variant during a routine dissection underscores several key points:

Enhancing Anatomical Knowledge

Cadaveric studies allow medical students and researchers to encounter rare anatomical variations that may not be covered in standard textbooks. This exposure broadens their understanding of human anatomy and its potential variations.

Preparing for Clinical Practice

Encountering unusual anatomical variants during training prepares future healthcare professionals for the diversity they may encounter in clinical practice. It encourages critical thinking and adaptability in diagnostic and treatment approaches.

Advancing Medical Research

Discoveries made during cadaveric studies can contribute significantly to medical literature and research. This case report, for instance, adds to the limited body of knowledge on right-sided hiatal hernias.

Contribution to Medical Literature

This case report makes a valuable contribution to the existing medical literature on hiatal hernias. By documenting this rare right-sided variant, it expands the understanding of potential anatomical variations in hiatal hernias.

Expanding Knowledge Base

The detailed description of this case provides important information for researchers and clinicians, including:

• The possibility of massive right-sided hiatal hernias
• The potential for complete stomach herniation
• The involvement of other abdominal structures like the omentum

Implications for Diagnosis and Treatment

This case report may influence future diagnostic and treatment approaches for hiatal hernias by:

• Encouraging consideration of right-sided hernias in differential diagnoses
• Informing surgical planning for unusual hernia presentations
• Highlighting the need for individualized treatment approaches

Future Research Directions

The discovery of this rare anatomical variant opens up several avenues for future research:

Prevalence Studies

Research could be conducted to determine the true prevalence of right-sided hiatal hernias. This might involve reviewing large numbers of imaging studies or conducting multi-center studies.

Genetic Factors

Investigating potential genetic factors that might predispose individuals to right-sided hiatal hernias could provide insights into the underlying mechanisms of hernia formation.

Long-Term Outcomes

Studies comparing the long-term outcomes of patients with right-sided versus left-sided hiatal hernias could reveal important differences in prognosis and treatment efficacy.

Surgical Techniques

Development and evaluation of specific surgical techniques for repairing right-sided hiatal hernias could improve patient outcomes.

In conclusion, this case report of a massive right-sided hiatal hernia provides valuable insights into a rare anatomical variant. It underscores the importance of thorough anatomical knowledge, the value of cadaveric studies, and the need for continued research in this area. As medical knowledge advances, cases like this contribute to a more comprehensive understanding of human anatomy and its variations, ultimately leading to improved patient care and outcomes.

Massive right-sided hiatal hernia variation

Molly Farrell^*,

Mahima Dhume,

Cara L Fisher and

Rustin Reeves

 

Center for Anatomical Sciences, University of North Texas Health Science Center, 3500 Camp Bowie Boulevard, Fort Worth, TX 76107, USA, Email: [email protected]

 

^*Correspondence:
Molly Farrell,
Center for Anatomical Sciences,
University of North Texas Health Science Center,
3500 Camp Bowie Boulevard, Fort Worth, TX 76107,
USA,
Tel: +8177352037,
Email: [email protected]

Received: 06-Jan-2019
Accepted Date: Jan 21, 2019;
Published:
31-Jan-2019, DOI: 10.37532/1308-4038.19.12.013

Citation: Farrell M, Dhume M, Fisher CL, et al. Massive right-sided hiatal hernia variation. Int J Anat Var. Mar 2019;12(1):013-014.

This open-access article is distributed under the terms of the Creative Commons Attribution Non-Commercial License (CC BY-NC) (http://creativecommons.org/licenses/by-nc/4.0/), which permits reuse, distribution and reproduction of the article, provided that the original work is properly cited and the reuse is restricted to noncommercial purposes. For commercial reuse, contact [email protected]

During routine cadaver dissection for academic purposes, a massive hiatal hernia was identified in an 84- year-old female cadaver. A herniation of abdominal contents was displaced into the right thoracic cavity, which contained the entire stomach, pyloric sphincter and portions of the greater and lesser omentums. Prior to death, there were no reports of significant functional abnormalities, although there were reports of gastrointestinal bleeding.

This case presents a rare variant due to two factors: the size of the esophageal hiatus and the displacement of the hernia into the right side of the thoracic cavity. The hiatal surface area (HSA) in this case report was calculated to be almost three times the established average HSA in normal patients. The majority of reported paraesophageal hernias (PEH) are left-sided with little mention of right-sided PEH in the literature. This case report attempts to add to the body of literature detailing right-sided hiatal hernias.

Keywords

Hiatal hernia; Variant; Paraesophageal hernia; Right sided; Massive

Introduction

The esophageal hiatus is an opening in the diaphragm at the T10
vertebral level that allows the esophagus and the vagal trunks to pass
into the abdominal cavity of the human body. A hiatal hernia describes a
herniation of abdominal contents, typically the stomach, through this hiatus
into the mediastinum. Classically, there are four types of hiatal hernias. Type
I is described as the sliding hiatal hernia, while types II-IV are considered
paraesophageal hernias (PEH). The sliding hiatal hernia is characterized
by displacement of the gastroesophageal junction (GEJ) superiorly and
portions of the gastric cardia herniating into the posterior mediastinum [1].
According to Watson (2018), 95% of hiatal hernias are classified as sliding
hiatal hernias, leaving 5% under type II-IV classifications. Type II herniation
presents with the GEJ in normal anatomic position, but with a gastric fundus
herniation [2]. Type III hiatal hernias have a superiorly displaced GEJ,
similar to the sliding hernia, and a large herniation of the stomach, similarly
to Type II. Lastly, Type IV hernias also have a superiorly displaced GEJ in
addition to herniation of other organs along with the stomach through the
esophageal hiatus. Most commonly, the colon herniates with the stomach
in Type IV hernias, but other organs may consist of the spleen, pancreas or
small intestines [1,2].

The reason for development of paraesophageal hernias are not clear, but it
is thought that increased age and intra-abdominal pressure could contribute
to the laxity of the external sphincter of the esophagogastric junction. That
laxity could allow abdominal contents to rise superiorly into the thoracic
cavity. Hiatal hernias can present acute symptoms such as obstructions,
which can lead to serious complications of bleeding, ischemia, perforation
and sepsis [3]. Many chronic clinical manifestations can also result from a
large hiatal hernia including dysphagia, nausea, vomiting, regurgitation,
heartburn, ulcers, anemia, poor emptying, and/or shortness of breath [3].
Patients with hiatal hernias may also be asymptomatic.

This anatomic variant case presents a massive Type IV hiatal hernia with
the abdominal contents of the stomach and portions of greater and lesser
omentums into the right thoracic cavity.

Case Report

During routine cadaver dissection in an anatomy lab course for first-year
medical students, a large hiatal hernia was identified on the right side of
the thoracic cavity in an 84-year-old female cadaver (Figure 1) The hernia
included 100% of the stomach, pyloric sphincter, and portions of the greater and lesser omentums. As a result, the diaphragm was displaced superiorly.
The esophageal hiatus extended from vertebral column levels T8-T12. The
hiatus measured 4.3 cm at the circuit between the crural edges and 8.3 cm
from the crural commissure to the most superior point of the hiatus. The left
crus measured 8.0 cm and the right crus measured 7.2 cm, and the distance
between the crura at the crural commissure measured 1.3 cm (Figure 2). The
cadaver outlined in this case report died from cardiac arrest. Prior to death,
the presence of the large hiatal hernia was known, but no there were no
descriptions of significant functional abnormalities. There were no reports
of postprandial symptoms or past treatments for the hiatal hernia. However,
there was a history of coronary artery disease and gastrointestinal bleeding,
which may have been related to the hernia.

Discussion

We believe this case to be a rare variant due to two factors: the size of the
esophageal hiatus and the displacement of the hernia to the right side of the
thoracic cavity. In a prospective study involving fifty cadavers wherein the
GEJ was intra-abdominal and the donors had died of problems unrelated to
gastroesophageal reflux disease, the HSA was measured to be 5.84 cm² [4].
The hiatal surface area (HSA) in this case report was calculated to be 17.41
cm², which is almost three times the established average HSA in normal
patients [5]. Researchers classify such cases as massive hiatal hernias if greater than 50% of the stomach has been displaced into the mediastinum [3]. This
particular case fulfills this criterion and qualifies as a massive hiatal hernia.

Additionally, the location of the hernia in this case report can be considered
rare. Through our literature review, only one case report was discovered
outlining three right-sided hernias thought to be congenital in origin [6].
These are found to have better prognosis and often are not discovered until
later in childhood because of early asymptomatic presentations. However,
chronic symptoms often can develop due to pressure on the hiatal ring
[6]. Another pediatric case report noted congenital hernia through other
diaphragmatic foramina [7]. Up to 90% of such hernias are noted to be
left-sided through the foramen of Bochdalek, whereas right -sided hernias
through the foramen of Morgagni are far less common than the former [7].

A study analyzing the laparoscopic repair of giant paraesophageal hernias
found that the repair of giant PEHs determined a favorably low rate of
symptom recurrence (9.9%), but also with a high rate of anatomic recurrence
rate (34.2%) [8]. Regarding the management of PEH, while surgery is
indicated in acute symptomatic cases, there are different schools of thought
regarding the necessity of surgical intervention for chronic asymptomatic
cases. However according to Duranceau, massive hiatal hernias, such as the
one in this case report, should undergo elective repair due to the possibility
of exacerbating symptoms and unforeseen complications [3].

Looking forward, we believe that there is great scope for future research
specific to right-sided hernias and the improvement in quality of life for
those who undergo elective surgery. It is interesting to consider that the
cadaver in this case study was relatively asymptomatic despite such a large
hernia in the right thoracic cavity. This poses questions regarding whether
this hernia was of congenital origin and if right sided hernias do have better
prognoses, as Haddad suggested. If the latter is true, this further poses the
question whether surgery would be indicated to the same extent as left sided
hiatal hernias. With this case report, we aim to add to the scarce literature
regarding right sided hiatal hernias to begin to answer such questions.

Acknowledgement

The authors would like to express their immense appreciation to the donors
for their generous and invaluable gift to the Center of Anatomical Sciences
Willed Body Program at the University of North Texas Health Science
Center.

REFERENCES

1. Kahrilas PJ, Kim HC, Pandolfino JE. Approaches to the diagnosis and grading of hiatal hernia. Best Prac Res Clin Gastroenterol. 2008; 22:601-16.
2. Watson TJ, Moritz T. Hernia, Sliding (Paraesophageal). StatPearl. 2018.
3. Duranceau A. Massive hiatal hernia: a review. Dis Esophagus. 2016;29:350-66.
4. Shamiyeh A, Szabo K, Granderath FA, et al. The esophageal hiatus: what is the normal size? Surg Endosc. 2010;24:988-91.
5. Granderath FA. Measurement of the esophageal hiatus by calculation of the hiatal surface area (HSA). Why, when and how? Surg Endosc. 2007; 21:2224-5.
6. Haddad MC, Youssef BA, Sammak BM, et al. Right intrathroacic stomach secondary to congenital hiatal hernia and organoaxial torsion. Am J Roentgenol. 1996;167:66-8.
7. Kaptanoglu M, Dogan K, Cevit O, et al. Right-sided hiatal henia of the oesophagus. Scand Cardiovasc J. 1999;33:54-6.
8. Antiporda M, Veenstra B, Jackson C, et al. Laparoscopic repair of giant paraesophageal hernia: are there factors associated with anatomic recurrence? Surg Endosc. 2017;32:945-54.

Hiatal Hernia the Great Mimicker

Hiatal Hernia has been one of my favourite conditions to treat. One of my first patients 1n 1980, while working as a student Intern came in with Chronic constant belching and epigastric pain. Using my newly acquired knowledge in AK
I found a classic weakness of the diaphragm and psoas muscles. Using Applied Kinesiology Chapman’s and neurolymphatic reflexes along with Chiropractic and simple exercises her symptoms of many years duration, fully resolved with in a few weeks.

Hiatal Hernia is a great mimicker of Heart Attacks (MI) and other issues in the abdominal, chest and thoracic spine regions. Essentially there is a weakness in the diaphragm’s opening (hiatus) for the oesophagus to go through. Pressure on or in the abdomen pushes the stomach up through the hiatus creating weakening of the Cardiac sphincter which then released hydrochloric acid from the stomach into the esopahagus (acid reflux). Its all to common. Treated medically with antacids gives temporary relief, but long term the antacids reduce the digestive tracts ability to breakdown proteins resulting in new digestive issues. We use AK reflexes to diagnose and treat the cause, usually a weakness of the diaphragm and psoas muscles. Finishing with home treatments of the reflexes and exercises the symptoms usually resolve till next Thanksgiving when a huge meal may recreate the weakness. Good news, the home treatment usually puts HH back into check. If not a few office visits with AK and Chiropractic will re clear the flare up.

Below are some excellent articles that go along and fairly well explain my treatment program along with some home self help.

Hiatal Hernia: An Overlooked Cause of Disease
Steven H. Horne 1997-2001

About three years ago Jack Richardson, a naturopathic physician, corrected a health problem I must have carried since childhood–a hiatal hernia. The impact this simple maneuver has had on my health has amazed me. I immediately noticed a difference in my lung capacity and my digestion and in the months that followed I began to put some muscle on my skin and bones frame and gain newfound strength and stamina.

Dr. Richardson tells me that this is a common health problem and my own observations as well as those of others confirm this fact. But this is more than a personal observation as the American Digestive Disease Society has estimated that nearly half of all adults–some 60 million people–have a hiatal hernia.

It occurs more often in women than in men. It affects people of all ages, but is most prevalent in people over 50 and highly likely in people over 65.

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The Great Mimic
Hiatal Hernia has been called the “great mimic” because it mimics many disorders. A person with this problem can get such severe pains in their chest that they think they are having a heart attack. They may think they have an over acid stomach because they will regurgitate stomach acid after they eat, or their stomach may hurt so badly they will think they have an ulcer. This is just a sampling of the symptoms that may occur from this disorder.

What is a Hiatal Hernia?
When you swallow, your food passes down a long tube known as the esophagus into the stomach. This tube must pass through a muscle known as the diaphragm, which is located near the bottom of your rib cage. This opening in the diaphragm, which permits the esophagus to pass through, is regulated by a sphincter muscle (or “valve”) which relaxes and opens when we swallow to permit the food to pass through the diaphragm and into the stomach. This sphincter then closes to prevent stomach acid from coming back up into the throat. A hiatal hernia occurs when the top of the stomach rolls or slides up into this opening and becomes stuck there.

Symptoms
Naturally, when part of the stomach is forced into this opening, the sphincter cannot close properly. Thus, stomach acid may travel back up into the esophagus causing burning sensations (heartburn), esophageal spasms, inflammations and ulcers.

The cramped position of the stomach can also stress the vagus nerve, which stimulates the release of hydrochloric acid. This can cause both over and under secretion of hydrochloric acid and stomach enzymes. It may also affect the sphincter or valve at the bottom of the stomach so that digestive secretions “leak” out of the stomach and are lost before they have completed their job.

The hiatal hernia will also interfere with the movement of the diaphragm muscle. This muscle normally pulls downward to expand the chest capacity and inflate the lungs. Since the hiatal hernia interferes with this movement, the person may be restricted to shallow breathing, or will resort to using the chest and shoulders to expand the lung capacity and take a deep breath.

The esophagus may also “kink” in the throat, which will irritate the thyroid gland and may cause some difficulty in swallowing. Often persons with hiatal hernias will have difficulty in swallowing capsules or tablets as they get the sensation that they are “sticking” in their throat.

The irritation on the vagus nerve can cause reflex irritations throughout the body. The vagus nerve comes from the medulla and goes to the heart, esophagus, lungs, stomach, small intestines, liver, gall bladder, pancreas and colon. It also has links to the kidney, bladder, and external genitalia. Thus, a hiatal hernia may start imbalances in the system such as decreased stomach acid and pH imbalance in the intestines and elsewhere.

If a person develops poor stomach digestion due to a lack of hydrochloric acid, they will have difficulty digesting and assimilating protein and most minerals. It will also contribute to food putrefaction in the intestines, causing greater toxicity in the body. This lack of nutrition and toxic condition may contribute towards food allergies, constipation, anemia and immune and glandular system weaknesses.

Two other problems that a hiatal hernia may contribute to are asthma and heart disease. Since the hernia reduces the lung capacity by interfering with natural breathing, it could be a factor in asthma. The hernia may also put pressure on the heart. Gas in the intestines may put pressure on the hernia and push it against the bottom of the heart, which may be one way in which a heart attack can be triggered. None of this spells immediate fatality, but it does point to a major contributing factor in degenerative illness.

Causes
The causes of a hiatal hernia are speculative and unique to each individual. However, there are a number causes. First of all there may be a mechanical cause. Improper lifting, hard coughing bouts heavy lifting, sharp blows to the abdomen (the kind that “knock the wind out of you”), tight clothing and poor posture may contribute to the development of this problem. Improper lifting may be the biggest mechanical cause of this disorder. If the air is not expelled out of a person’s lungs while lifting, it will force the stomach into the esophagus.

Secondly, there are dietary causes. Hiatal hernia just about always accompanies a swollen ileocecal valve. The ileocecal valve is the valve between the small and large intestines which permits material to enter the colon from the large intestine, but prevents material in the colon from moving back into the small intestine. When this valve becomes swollen and irritated it cannot close properly. This allows material from the colon to leak back into the small intestine. This is analogous your sewer backing up into your kitchen. This creates gas and indigestion, which puts pressure on the stomach and presses it tighter against the diaphragm.

The relationship between the ileocecal valve and the hiatal hernia is a chicken/egg situation … it is hard to know which comes first. However, it is clear that the ileocecal problem aggravates the hernia. Hence, the things which irritate that valve may be causal factors. These are the basic causes of digestive problems: poor food combining, overeating, drinking with meals, overeating and eating when upset.

Lastly, there are emotional causes. According to one applied kinesiologist text a hiatal hernia comes from repressed anger. A person “swallows their anger” and “can’t stomach it.” When you get angry, you suck your breath upward. If you fail to release this anger, your stomach stays up. I have observed that most of the people with severe hiatal hernias have a great deal of emotional stress and hold a lot of it inside.

Identification
The easiest way to tell if you or someone you know has a hiatal hernia is to place your fingers on the solar Plexus, just below the breastbone. Then take a deep breath. You should feel the solar plexus expand and move outward. If there is no movement at the solar plexus and you have to lift your chest and shoulders to take a deep breath, then you probably have a hiatal hernia. You should be able to take a deep abdominal breath without lifting your shoulders.

There are other, more complicated, methods of determining if you have a hiatal hernia, such as muscle testing, but this is a fairly simple and reliable method.

Correction
Since a hiatal hernia is primarily a mechanical problem, the easiest and best way to correct it is mechanically. Medical doctors have attempted surgery to correct this disorder, but the results tend to be poor. Cutting into this area can further weaken it so that the hernia will return in short order. A better method is to manipulate the stomach and bring down the hernia by hand. Unfortunately, you can’t do this to yourself. You will need to find a good chiropractor, applied kinesiologist or massage therapist who understands this problems and knows how to correct it.

If you want to learn how to do this adjustment to others, you will have to find someone who does it and have them show you how since it is impossible to adequately describe the technique(s) in writing. They have to be learned through demonstration and practice. ..

Self-Adjustment
There are some self-help adjustment techniques. They aren’t as effective as having someone else perform the adjustment, but they may help. The best one I’ve tried is to drink a pint of warm water first thing in the morning, then stand on your toes and drop suddenly to your heels several times. The warm water helps to relax the stomach and diaphragm and puts some weight in the stomach. By dropping down suddenly, the weight of the water helps to pull the stomach down. In a mild case, this might be enough to bring the hernia down. In a more severe case it may loosen the stomach and make it easier for someone else to bring it down. It will also help you to keep the stomach down once mechanical corrections have been made.

Nutritional Aids
Until the problem is corrected mechanically, there are some nutritional therapies which may be of help. Immediate, but temporary, relief of pain and discomfort can often be achieved by the use of a mucilaginous herb like slippery elm or comfrey. These herbs absorb the digestive secretions and help to prevent their traveling back up the esophagus and burning it. They also help to prevent irritation of the ileocecal valve. Comfrey can also speed the healing of this problem once mechanical adjustments have been made. Okra pepsin is a good combination for this problem as well.

Marshmallow is also helpful in soothing the mucous membranes for hiatal hernias and other ulcerations in the gastrointestinal system.

A digestive aid will help the person obtain the nutrients they need when the hernia is interfering with digestion.

This may take the form of a hydrochloric acid supplement or a food enzyme tablet, or perhaps an herbal digestive aid such as papaya and peppermint, chamomile tea, safflowers, ginger root and so forth.

Other food or herb products that have been used to help people with hiatal hernias include: raw cabbage juice (where ulcerations have occurred), balm, barley water, brown rice, celery, coriander, gentian, hops, licorice, marshmallow and passion flower.

Dietary modifications may be necessary to relieve the problem and to keep it from reoccurring once it has been corrected. Since the pressure of abdominal gas can push the stomach upward, it would be advisable to avoid gas forming foods like beans. It would also be wise to watch food combinations carefully and to avoid overeating. Dr. Jack Ritchason recommends that people with hiatal hernias avoid eating any heavy meals after 3 pm.

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Symptoms of a Hiatal Hernia

What is a Hiatal Hernia?

A hiatal hernia occurs when the top of the stomach rolls or slides up into the opening in the diaphragm which the esophagus passes through and becomes stuck there.

This condition may create difficulty with digestion (and hence general nutrition and well-being) as well as breathing difficulties, nervous problems, circulatory problems and glandular imbalances. All of the following symptoms have been connected with a hiatal hernia. If you have some of these symptoms especially those marked with an asterisk (*) you may wish to consider being checked for this condition.

DIGESTIVE DIFFICULTIES
*Belching, *Bloating, *Heartburn, *Difficulty digesting meat/high protein foods, Tension or pressure at the solar plexus, Sensitivity at the waist, Intestinal gas, Regurgitation, Hiccups, Lack or limitation of appetite, Nausea, Vomiting, Diarrhea, Constipation, Colic in children, Difficulty in gaining weight or overweight, Ulcers.

BREATHING AND CIRCULATION PROBLEMS
*Difficulty with deep abdominal breathing, *Difficulty in swallowing capsules, *Asthma, *Inability to take a deep breath from diaphragm, Overall fatigue, Tendency to swallow air, Allergies, Dry tickling cough, Full feeling at base of throat, Pain or burning in upper chest, Pressure in the chest, Pain in the left side of chest, Pressure below breastbone, Lung pain, Rapid heartbeat, Rapid rise in blood pressure, Pain in left shoulder, arm or side of neck.

STRUCTURAL COMPLAINTS
TMJ (Temporo-Mandibular Joint Pain), Bruxism (Grinding teeth in sleep), Joint pain, Localized or overall spinal pain, Headaches.

STRESS
*Suppression of anger or other emotions, *Living with or having lived with a quick-tempered person, Dizziness, Shakiness, Mental Confusion, Anxiety attacks, Insomnia, Hyperactivity in children.

OTHER AILMENTS
*Open ileocecal valve, *General weakness, *Difficulty in getting and/or staying healthy, Overactive thyroid, Cravings for sugar or alcohol, Candida Albicans, Menstrual or prostate problems, Urinary difficulties, Hoarseness.

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Nature’s Field, Vol.17 No.3, May/June 2001
Steps for Manual Manipulation of a Hiatal Hernia
Laura McCready, N.D.

This procedure can be performed on yourselfafter being shown the technique by your natural health practitioner.

Perform this procedure every morning for at least one month, two months for large or long-term hernias. Steps one and two are optional but should be done for tense individuals or stubborn hernias. This procedure can be performed anytime the stomach seems to be displaced but best results are achieved if this is done with an empty stomach.

1. Five minutes before the procedure, take a dropperful (15-20 drops) each of Lobelia Essence (stock # 1765-8) and Stress-J Liquid (stock # 3163-3) in 2 ounces of warm water to relax the diaphragm and vagus nerve.
   Magnesium Complex (stock # 1859-8) can also be taken daily to promote muscle relaxation.
2. Massage Tei Fu Oil (stock # 1618-7), Lavender Essential Oil or Chamomile Essential Oil into the stomach area before the procedure.
3. Lie on your back on a hard flat surface or the floor. Take a deep breath and remember what it feels like. (You should be able to breathe deeper and easier when the procedure is over.)
4. Place both hands just beneath the breastbone. Palms are against the body and fingers are touching so that the thumbs meet just below (1″-2″) where the ribs come together.
5. Take a deep breath and as you slowly and forcefully exhale, push thumbs inward and downward about two inches with a steady, heavy pressure. Do not lift your hands or release the pressure on your abdomen at the end of the breath.
6. Maintaining constant pressure with the thumbs, take another breath and repeat the procedure until you reach the waistline. This will take a total of about 3-5 breaths.
7. Hold your left thumb in place and move your right thumb over to shut the ileocecal valve. Using your right thumb this valve is found by locating the front, upper point of the right hip bone and moving the thumb toward the center of the body two inches and then down two inches. (This valve must be closed in order for the gastroesophageal valve to remain closed.)
8. As your right thumb applies pressure to the ileocecal valve in an inward and upward direction (toward the stomach) move the left thumb over to assist with the pressure. Hold this pressure for 30 seconds. Release with a slight wiggling, massaging motion.
9. Repeat the entire procedure (steps 4-8) three times.
   Take a deep breath and see how much better you feel.
10. To Avoid pressure on the stomach, DO NOT rise as if you were doing a sit-up. Roll onto your side and push yourself to a sitting position using your arms rather than lifting yourself using your abdominal muscles.

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Health Parameters Research site.
Abdominal Massage
Pat Block, N.D., 2000.

Treatment of diaphragmatic hernia

HomeServicesGeneral surgeryTreatment of diaphragmatic hernia

Who needs surgical treatment for hiatal hernia?

The goal of surgical treatment for a hiatal hernia is to eliminate or significantly reduce the existing symptoms of a hernia (heartburn, discomfort and pain in the chest, shortness of breath, regurgitation), as well as restore normal anatomy.

Surgical treatment saves the patient from the need for drug treatment, improves the quality of life, eliminates the threat of severe complications of hernia and reflux in the form of strangulation, bleeding, narrowing of the esophagus, etc., eliminates the inflammatory process in the esophageal wall and improves its function.

Elimination of hiatal hernia is necessary for patients with paraesophageal (paraesophageal) hernia due to the risk of its infringement in the presence of symptoms, as well as for patients with sliding hiatal hernia, which has severe clinical manifestations in the form of heartburn, regurgitation (regurgitation) of food and requiring constant medical treatment. The operation is indicated for patients with diaphragmatic hernia with such complications as esophageal ulcer, its narrowing (stricture), Barrett’s esophagus. Diaphragm hernia without surgery over time tends to increase, compression of the lungs and mediastinal organs, and can lead to infringement. Patients with atypical symptoms of reflux (relapses of pneumonia and bronchitis, nocturnal cough, hoarseness) to prove the connection of these symptoms with a diaphragmatic hernia, it is necessary to conduct pH measurements before surgery. In the presence of excruciating heartburn in patients without diaphragmatic hernia or with a small hernia, esophageal manometry should be performed before surgery to rule out esophageal achalasia .

Figure – Different types of hiatal hernia

Why is it better to perform the operation in the Medica Medical Clinical Center?

Our center uses only laparoscopic access, which is easily tolerated by patients, allowing you to quickly return to your usual lifestyle and physical activity. Operations are performed by an expert specializing in this problem. Diagnosis and treatment of a short esophagus in combination with a diaphragmatic hernia is carried out. Careful technical implementation of the technique, which has proven itself in the world and in Russia, is the prevention of new pathological syndromes associated with the operation. Laparoscopic fundoplication in our center is performed in the variant of full or partial fundoplication (“short soft” Nissen, Tupe technique). During repeated operations for diaphragmatic hernia, we perform a symmetrical fundoplication according to A.F. Chernousov, if necessary, we perform lengthening of the esophagus.

Drawing – Nissen fundoplication and suturing of the crura of the diaphragm (diagram)

The use of the best fundoplication techniques, selective meshing, adherence to indications, search and preservation of nerves during surgery can relieve the existing symptoms of patients with any type of diaphragmatic hernia, including giant hernias with complete migration of the stomach into the mediastinum.

In patients with shortening of the esophagus , to prevent complications and reduce the risk of hernia recurrence – simultaneously with the removal of the hernia, fundoplication, we perform lengthening of the esophagus according to Collis-Nissen .

Drawing – Elongation of the esophagus due to the wall of the stomach – Collis-Nissen operation (scheme)

For patients with morbid (morbid) obesity with a body mass index of more than 35 kg/m2 in combination with a hiatal hernia with severe clinical manifestations, according to existing international clinical guidelines, it is advisable to perform bariatric intervention (gastric bypass or longitudinal gastroplasty).

To prevent the recurrence of diaphragmatic hernia in patients with giant hernias, atrophy (thinning) of the diaphragmatic crura and, as a rule, with obesity, laparoscopy may determine the need for setting mesh – in the form of circular or U-plasty. To do this, our center is forced to use a macroporous polypropylene mesh with a mesh size of 1.5 mm or more, which quickly integrates into tissues and does not tend to wrinkle. The use of such a mesh reduces the number of recurrences of diaphragmatic hernia by 5-7 times in the long term and is accompanied by complications in less than 1% of patients (mesh migration into the lumen of the esophagus).