Pain from hiatal hernia right side. Hiatal Hernia: Causes, Symptoms, and Treatment Options

09.07.202326.06.2023 by alexxlab

What is a hiatal hernia. How does it affect the digestive system. What are the common symptoms of a hiatal hernia. What causes hiatal hernias to develop. How are hiatal hernias diagnosed and treated. Can hiatal hernias be prevented. When should you see a doctor for hiatal hernia symptoms.

Содержание

Understanding Hiatal Hernias: An Overview of the Condition

A hiatal hernia occurs when a portion of the stomach pushes upward through the diaphragm, the muscular wall separating the chest cavity from the abdomen. This condition can lead to various digestive symptoms and complications if left untreated. To fully grasp the nature of hiatal hernias, it’s crucial to understand the anatomy of the upper digestive system and how this condition affects its normal functioning.

The Anatomy of the Upper Digestive System

The upper digestive system consists of several key components:

Esophagus: The tube that carries food from the mouth to the stomach
Stomach: Where food is mixed with digestive juices and broken down
Diaphragm: A large, flat muscle that separates the chest cavity from the abdomen
Lower esophageal sphincter (LES): A ring of muscle at the junction of the esophagus and stomach that prevents stomach contents from flowing back into the esophagus

In a normal digestive system, the esophagus passes through an opening in the diaphragm called the hiatus before connecting to the stomach. The LES, along with the surrounding diaphragm muscle fibers, helps keep the junction closed when not swallowing, preventing acid reflux.

Types of Hiatal Hernias: Sliding vs. Para-esophageal

There are two main types of hiatal hernias, each with distinct characteristics and potential complications:

Sliding Hiatal Hernias

Sliding hiatal hernias are the most common type, accounting for about 95% of cases. In this type:

The gastroesophageal junction (where the esophagus meets the stomach) and a portion of the stomach slide up through the hiatus into the chest cavity
The hernia may move in and out of the chest cavity as you breathe or swallow
This type is often associated with gastroesophageal reflux disease (GERD) symptoms

Para-esophageal Hiatal Hernias

Para-esophageal hernias, also known as rolling hiatal hernias, are less common but potentially more serious:

A portion of the stomach pushes up through the hiatus alongside the esophagus
The gastroesophageal junction remains in its normal position
This type carries a higher risk of complications, such as stomach strangulation or obstruction

Is it possible for other organs to be involved in a hiatal hernia? In rare cases, other abdominal organs such as the pancreas, spleen, or small intestine may protrude through the hiatus along with the stomach in a para-esophageal hernia.

Common Symptoms and Complications of Hiatal Hernias

Many people with hiatal hernias may not experience any symptoms. However, when symptoms do occur, they can vary in severity and may include:

Heartburn, especially after meals or when lying down
Regurgitation of food or sour liquid
Difficulty swallowing
Chest or abdominal pain
Shortness of breath
Feeling unusually full after eating

Do hiatal hernias always cause symptoms? Not necessarily. Many people with small hiatal hernias may be asymptomatic or experience only mild, occasional discomfort.

Potential Complications

While most hiatal hernias do not lead to serious complications, some potential risks include:

Chronic gastroesophageal reflux disease (GERD)
Esophagitis (inflammation of the esophagus)
Barrett’s esophagus (precancerous changes in the esophageal lining)
Esophageal stricture (narrowing of the esophagus)
Strangulation or obstruction (in severe cases of para-esophageal hernias)

Causes and Risk Factors for Hiatal Hernia Development

The exact cause of hiatal hernias is not always clear, but several factors may contribute to their development:

Age-related Changes

As we age, the supportive tissues around the hiatus may weaken, making it easier for the stomach to push through. This is why hiatal hernias are more common in people over 50 years old.

Increased Abdominal Pressure

Conditions or activities that increase pressure within the abdomen can contribute to hiatal hernia formation:

Obesity
Pregnancy
Chronic coughing or vomiting
Straining during bowel movements
Heavy lifting or physical exertion

Genetic Factors

There may be a genetic component to hiatal hernias, as they tend to run in families. However, more research is needed to fully understand the hereditary aspects of this condition.

Traumatic Injury

In some cases, a hiatal hernia may develop following a traumatic injury to the chest or abdomen.

Can lifestyle changes help prevent hiatal hernias? While not all hiatal hernias can be prevented, maintaining a healthy weight, avoiding heavy lifting, and managing conditions that cause chronic coughing may help reduce your risk.

Diagnostic Approaches for Hiatal Hernias

Diagnosing a hiatal hernia typically involves a combination of medical history review, physical examination, and diagnostic tests. The following methods may be used:

Barium Swallow Study

This imaging test involves swallowing a contrast liquid (barium) and then taking X-rays of the upper digestive tract. The barium highlights the esophagus and stomach, allowing the doctor to visualize any abnormalities, including hiatal hernias.

Endoscopy

An endoscope, a thin, flexible tube with a camera, is inserted through the mouth and down the esophagus. This allows the doctor to directly visualize the upper digestive tract and identify any herniation or related issues.

Manometry

This test measures the pressure within the esophagus and lower esophageal sphincter, which can help identify any functional abnormalities associated with a hiatal hernia.

CT Scan or MRI

In some cases, advanced imaging techniques may be used to get a detailed view of the chest and abdominal cavities, particularly for para-esophageal hernias.

How accurate are these diagnostic methods? While each test has its strengths, a combination of techniques is often used to ensure an accurate diagnosis and assess the severity of the hernia.

Treatment Options for Hiatal Hernias: From Lifestyle Changes to Surgery

The treatment approach for hiatal hernias depends on the severity of symptoms and the type of hernia. Options range from conservative management to surgical intervention:

Lifestyle Modifications

For mild cases, lifestyle changes may be sufficient to manage symptoms:

Eating smaller, more frequent meals
Avoiding trigger foods that exacerbate reflux
Not lying down immediately after eating
Elevating the head of the bed
Losing weight if overweight or obese
Quitting smoking

Medications

Various medications can help manage symptoms associated with hiatal hernias:

Antacids for quick relief of heartburn
H2 receptor blockers to reduce stomach acid production
Proton pump inhibitors (PPIs) for long-term acid suppression

Surgical Intervention

Surgery may be recommended for large hernias, severe symptoms, or complications. Common surgical approaches include:

Nissen fundoplication: The upper part of the stomach is wrapped around the lower esophagus to reinforce the sphincter
Hernia repair: The stomach is pulled back into the abdomen, and the diaphragm opening is tightened

Are there minimally invasive surgical options for hiatal hernia repair? Yes, many hiatal hernia surgeries can now be performed laparoscopically, using small incisions and a camera, which can lead to faster recovery times and fewer complications compared to open surgery.

Living with a Hiatal Hernia: Management and Long-term Outlook

For many people, living with a hiatal hernia involves ongoing management to minimize symptoms and prevent complications. Here are some strategies for long-term management:

Dietary Considerations

Adopting a “hiatal hernia-friendly” diet can help reduce symptoms:

Avoid foods that trigger reflux, such as spicy, fatty, or acidic foods
Eat smaller portions more frequently throughout the day
Stay upright for at least three hours after eating
Limit alcohol and caffeine consumption

Stress Management

Stress can exacerbate symptoms of hiatal hernias. Incorporating stress-reduction techniques into your daily routine can be beneficial:

Practice relaxation techniques like deep breathing or meditation
Engage in regular physical activity, such as walking or yoga
Get adequate sleep
Seek support from friends, family, or a therapist if needed

Regular Monitoring

Even with successful management, it’s important to monitor your condition:

Attend regular check-ups with your healthcare provider
Report any new or worsening symptoms promptly
Follow through with recommended screenings, especially if you have chronic GERD

Can hiatal hernias recur after treatment? While recurrence is possible, especially after non-surgical treatments, many people experience long-term relief with proper management or surgical intervention. The risk of recurrence can be minimized by maintaining a healthy lifestyle and following medical advice.

When to Seek Medical Attention for Hiatal Hernia Symptoms

While many cases of hiatal hernia can be managed with lifestyle changes and medication, there are situations where immediate medical attention is necessary. Be aware of the following warning signs:

Severe or Persistent Symptoms

Seek medical care if you experience:

Severe chest pain or pressure that could be mistaken for a heart attack
Difficulty swallowing that persists or worsens
Vomiting of blood or passing of black, tarry stools (which may indicate gastrointestinal bleeding)
Shortness of breath, especially if it’s new or worsening

Signs of Complications

Watch for symptoms that could indicate a complication of hiatal hernia:

Severe, constant abdominal pain
Fever accompanied by chest or abdominal pain
Inability to have a bowel movement or pass gas

How quickly should you seek medical attention for these symptoms? If you experience severe chest pain, difficulty breathing, or signs of gastrointestinal bleeding, seek emergency medical care immediately. For other concerning symptoms, contact your healthcare provider promptly for guidance.

Understanding hiatal hernias, their symptoms, and treatment options is crucial for managing this common condition effectively. While many people with hiatal hernias may experience minimal discomfort, others may require more intensive management or surgical intervention. By working closely with healthcare providers and adopting appropriate lifestyle changes, individuals with hiatal hernias can often find relief and prevent complications, leading to an improved quality of life.

Hiatus Hernia: Causes, Symptoms, and Treatment

In this series Acid Reflux and Oesophagitis (Heartburn) Barrett’s Oesophagus Barium Tests (Swallow, Meal, Follow Through)

Hiatus hernia is the term used to describe a condition where part of the stomach pushes up into the lower chest through a weakness in the diaphragm. The diaphragm is the large flat muscle that separates the lungs from the tummy (abdomen) and helps us to breathe. Not everyone with a hiatus hernia develops symptoms. However, if you have a hiatus hernia you are more prone to reflux acid into your gullet (oesophagus), which can cause heartburn and other symptoms. If symptoms do occur, treatment with acid-suppressing medication usually works well.

Understanding the upper gut

The gut (gastrointestinal tract) is the tube that starts at the mouth and ends at the back passage (anus).

The upper gut includes the gullet (oesophagus), stomach and the first part of the small intestine (the duodenum). Food passes down the oesophagus into the stomach. The stomach makes acid which helps to digest food. After being mixed in the stomach, food passes into the duodenum to be digested by the digestive system.

Diagram of upper gut and nearby organs

Diagram of normal stomach

The walls of the stomach contain muscle. At the junction of the stomach and the oesophagus there is a thickened area of muscle which is called a sphincter. The sphincter acts like a valve. When food comes down the oesophagus into the stomach, the sphincter relaxes. However, it closes at other times to stop food and acid in the stomach going back up (refluxing) into the oesophagus.

The diaphragm is a large flat muscle that separates the lungs from the tummy (abdomen). It helps us to breathe.

The oesophagus comes through a hole (hiatus) in the diaphragm just before it joins to the stomach. Normally, all of the stomach is below the diaphragm. The muscle fibres in the diaphragm around the lower oesophagus help the sphincter to keep the oesophagus closed to prevent reflux of acid and food.

What is a hernia?

A hernia occurs when part of an organ pushes (protrudes) through a muscular wall that holds it in place. There are different types of hernia. For example, an inguinal hernia is the most common type when part of the lower bowel protrudes through the muscle in the groin.

What is a hiatus hernia?

A hiatus hernia occurs when part of one of the organs in the tummy protrudes through the diaphragm. Most commonly this is a part of the stomach; however, it may be other organs, such as the pancreas, spleen or the upper gut (small intestine).

Types of hiatus hernia

Sliding hiatus hernias

This is the most common type. In this situation, the sphincter muscle at the bottom of the gullet (oesophagus) and the top of the stomach protrudes through the hole (hiatus) opening in the diaphragm. This is the muscle separating the lungs from the tummy (abdomen). The hernia may slide up and down, in and out of the lower chest. It is often quite small. This type of hiatus hernia tends to be associated with symptoms of acid reflux (see below.)

Para-oesophageal hiatus hernia (also called a rolling hiatus hernias)

This type is less common. In this situation, a part of the stomach pushes (protrudes) up through the hole in the diaphragm next to the oesophagus. Other organs from the tummy can also protrude through the hole in some cases. This could be the pancreas, the spleen or the upper gut (small intestine). This is not the normal type of hiatus hernia and it is much less common than a sliding hiatus hernia. It is more risky, as there is more chance the organ protruding can get stuck, causing a blockage (obstruction).

Diagram of sliding hiatus hernia

Diagram of rolling hiatus hernia

You may also see hiatus hernias referred to as types 1-4 depending on where the stomach and oesophagus are in relation to the diaphragm.

How common is it?

The exact number of people with a hiatus hernia is not known, as many people with a hiatus hernia do not have symptoms. However, they are thought to be common. Some studies suggest that up to half of people having tests for indigestion (dyspepsia) are discovered to have a hiatus hernia.

What causes a hiatus hernia?

The cause of hiatus hernia is not clear. It is thought that most develop in people over the age of 50 years. It may be that the diaphragm muscle weakens with age. This allows part of the stomach to protrude through the hole in the diaphragm. Factors which increase the pressure in the tummy (abdomen), such as regular coughing, repeated lifting of heavy objects, or obesity, may increase the risk of developing a hiatus hernia. It may be more likely if one of your close relatives has a hiatus hernia.

Operations around the stomach and gullet can make you more likely to get the para-oesophageal type of hiatus hernia. You are also more likely to get this type if your spine or rib cage is more curved than usual. For example, people with scoliosis or kyphosis.

There is a rare type of hiatus hernia which occurs in newborn babies, due to a congenital defect of the stomach or diaphragm. ‘Congenital’ means that the condition is present from birth. This rare type is not dealt with further in this leaflet.

What are the symptoms of a hiatus hernia?

Often there are none

Many people have no hiatal hernia symptoms.

Acid reflux symptoms

The hernia itself does not cause symptoms. However, if you have a hiatus hernia, the factors that normally prevent stomach acid from refluxing into the gullet (oesophagus) may not work so well. The sphincter muscle may not work properly. The normal pressure of the diaphragm muscle on the oesophagus is lost. Therefore, you are more prone for acid in the stomach to go back upwards (reflux) into your oesophagus. The refluxed acid can cause inflammation of the lower part of the oesophagus. This can cause one or more of the following symptoms:

Heartburn: this is the main symptom. This is a burning feeling which rises from the upper tummy (abdomen) or lower chest up towards the neck.
Pain in the upper abdomen and chest.
Feeling sick.
An acid taste in the mouth.
Bloating.
Belching.
Difficulty swallowing.
A burning pain when you swallow hot drinks.

These symptoms tend to come and go and tend to be worse after a meal.

Some uncommon symptoms may occur. If any of these symptoms occur, it can make the diagnosis difficult, as these symptoms can mimic other conditions. For example:

A persistent cough, particularly at night, sometimes occurs. This is due to the refluxed acid irritating the windpipe (trachea). Asthma-like symptoms of cough and wheeze can sometimes be due to acid reflux.
Other mouth and throat symptoms sometimes occur such as gum problems, bad breath, sore throat, hoarseness and a feeling of a lump in the throat.
Severe chest pain develops in some cases (and may be mistaken for a heart attack).
Rarely, in people with a para-oesophageal hernia, the symptoms can be those of a part of the bowel being blocked (obstructed). In this case there would be severe tummy pain or chest pain, with retching or being sick (vomiting).

Note: many people with acid reflux do not have a hiatus hernia. Also, many people with a hiatus hernia do not have symptoms of acid reflux. If you have a hiatus hernia it does not necessarily mean that the sphincter between the oesophagus and stomach does not work so well. It is just that having a hiatus hernia makes you more prone to having a poorly functioning sphincter and more prone to developing acid reflux symptoms.

However, people with a hiatus hernia who do get reflux, on average, tend to get more severe symptoms and problems associated with acid reflux. This may be because with a hiatus hernia any acid that gets into the oesophagus is more likely to remain in contact with the lining of the oesophagus for longer compared with people without a hiatus hernia. See the separate leaflet called Acid Reflux and Oesophagitis (Heartburn) for more details.

How is a hiatus hernia diagnosed?

A hiatus hernia may be diagnosed if you have tests for symptoms of reflux. A special X-ray test called a barium swallow is sometimes used to confirm the presence of a hiatus hernia. Endoscopy is increasingly being used for diagnosis. An endoscope is a thin, flexible telescope which is passed down the gullet (oesophagus) into the stomach. This allows a doctor or nurse to look inside. A hiatus hernia may be seen. Occasionally other tests are needed.

What is the best treatment for hiatus hernia?

No treatment in some cases

If you have no symptoms, in most cases you do not need any treatment. The hiatus hernia usually causes no harm. Occasionally, if you have a hernia which is at risk of complications, you may be offered surgery, even if you do not have any symptoms.

Lifestyle changes

If you have reflux symptoms, you should aim to lose weight if you are overweight.
Avoid anything that causes pressure on your stomach, such as tight clothing and corsets.
If you are a smoker you should aim to stop. If you drink a lot of alcohol, it also helps to cut down on alcohol.
Raising the head of your bed may help with symptoms at night.
Avoiding eating your dinner too close to bedtime may also help with symptoms at night. Aim to have your dinner at least three hours before you go to bed ideally.
Smaller meals may be helpful, as may avoiding foods which you find make the reflux worse.

Medicines for hiatus hernia

If changing your lifestyle does not help, you may need medication. Medicines which reduce the action or production of stomach acid may help. The most effective medicines are proton pump inhibitors (PPIs). PPIs often used are omeprazole or lansoprazole. If these do not suit you, your doctor will offer other options. Recent studies have raised questions about whether long-term PPIs are linked to stomach cancer. More research is needed. The current advice is to take PPIs at the lowest dose and for the shortest period of time possible; some people find they can get by taking them occasionally rather than every day. However, if other medicines do not help and your symptoms cause persistent problems, you should carry on with them for as long as required.

An operation

Rarely, a hiatus hernia causes severe symptoms of reflux which are not helped so well with medication. Therefore, an operation is occasionally advised. It may also be advisable if you cannot tolerate the medication for some reason. During this operation the stomach is put back into the correct position and the weakened diaphragm muscle around the lower gullet (oesophagus) is tightened. The operation is usually done these days using a laparoscope (a telescope inserted into the stomach). The operation quite often needs repeating in due course.

What are the possible complications of a hiatus hernia?

Possible complications may occur if you have long-term reflux of acid into the gullet (oesophagus), which occurs in some cases. These include:

Oesophagitis

This is an inflammation of the lining of the gullet, caused by the acid washing against it over time. This can usually be treated with PPIs as mentioned above.

Cough

Sometimes the acid reflux can go back up and affect the voice box area (larynx) and give you a constant tickly cough. This can also usually be treated successfully with anti-reflux medicines.

Narrowing (a stricture)

If you have severe and long-standing inflammation it can cause scarring and narrowing of the lower oesophagus. This is uncommon.

Twisting (volvulus)

This is also known as a strangulated hernia (trapping of the hernia with blockage of the blood supply). This is a rare complication which can occur with the uncommon para-oesophageal type of hiatus hernia.

Barrett’s oesophagus

The lining of the oesophagus is made up of a number of units called cells. In Barrett’s oesophagus the cells that line the lower oesophagus change. The changed cells are more prone than usual to becoming cancerous. (About 1 in 20 men and 1 in 33 women with Barrett’s oesophagus develop cancer of the oesophagus. )

Cancer

Your risk of developing cancer of the oesophagus is slightly increased compared with the normal risk if you have long-term acid reflux. This small increased risk is slightly higher still in people with reflux plus a hiatus hernia. This is because reflux problems, on average, tend to be more severe in people with a hiatus hernia compared to those without a hiatus hernia.

Note: it has to be stressed that most people with reflux or hiatus hernia do not develop any of these complications. They are uncommon. Tell your doctor if you have pain or difficulty when you swallow (food sticking), which may be the first symptom of a complication. See your doctor if your symptoms aren’t being controlled by the medicines you have been prescribed, or if there is any change.

Hiatus hernia – Illnesses & conditions

Treatment for a hiatus hernia is usually only necessary if it’s causing problems.

In most cases, people with a hiatus hernia only experience problems if the hernia causes gastro-oesophageal reflux disease (GORD). GORD can cause symptoms such as heartburn and an unpleasant taste in your mouth.

Lifestyle changes and medication are the preferred treatments, although surgery may be used as an alternative to long-term medication, or if other treatments are ineffective.

Lifestyle changes

There are several things you can do yourself to help relieve symptoms of GORD caused by a hiatus hernia. These include:

eating smaller, more frequent meals, rather than three large meals a day
avoiding lying down (including going to bed) for at least 3 hours after eating or drinking
avoiding drinking during the night
removing certain foods from your diet if you think they make your symptoms worse
avoiding alcohol, caffeine, chocolate, tomatoes, fatty foods, spicy foods and acidic food or drinks, such as citrus fruit juice, if they make your symptoms worse
avoiding bending over or stooping, particularly after eating or drinking
raising the head of your bed by around 20cm (8 inches) by placing a piece of wood or blocks under it; don’t use extra pillows, because this may increase pressure on your abdomen

If you’re overweight, losing weight may help to reduce the severity and frequency of your symptoms.

If you smoke, you should try to give up. Tobacco smoke can irritate your digestive system and may make your symptoms worse.

Read about stopping smoking.

Medication

A number of different medications can be used to treat symptoms of hiatus hernia. These are described below.

Antacids

Antacid medicines can relieve some of the symptoms of hiatus hernia. They come in liquid or tablet form and can be swallowed or chewed. They help to neutralise stomach acid when they reach the oesophagus and stomach by making it less acidic.

However, antacid medicines don’t work for everyone. They’re not a long-term solution if symptoms persist or you’re in extreme discomfort.

Antacids shouldn’t be taken at the same time as other medicines, because they can stop other medicines from being properly absorbed by your body. They may also damage the special coating on some types of tablets. Ask your GP or pharmacist for advice.

Alginates

Alginates are an alternative medicine to antacids. They work by producing a protective coating that shields the lining of your stomach and oesophagus from the effects of stomach acid.

h3-receptor antagonists

In some cases, a medicine known as an h3-receptor antagonist (h3RA) may be recommended if a hiatus hernia is causing GORD. Examples of h3RAs include cimetidine, famotidine (PepcidTwo) and ranitidine.

h3RAs block the effects of the chemical histamine, which your body uses to produce stomach acid. h3RAs therefore help to reduce the amount of acid in your stomach.

Side effects of h3RAs are uncommon. However, possible side effects may include diarrhoea, headaches, tiredness and a rash.

Some h3RAs are available over the counter at pharmacies. These types of HR2As are taken in a lower dosage than the ones available on prescription. Ask your GP or pharmacist if you’re not sure whether these medicines are suitable for you.

Proton-pump inhibitors (PPIs)

Your GP may prescribe a medication called a proton-pump inhibitor (PPI). PPIs work by reducing the amount of acid produced by your stomach. Examples of the PPIs you may be prescribed include omeprazole, lansoprazole, rabeprazole and esomeprazole.

Most people tolerate PPIs well and side effects are uncommon. When they do occur, they’re usually mild and can include headaches, diarrhoea, feeling sick or constipation.

To minimise any side effects, your GP will prescribe the lowest possible dose of PPIs they think will be effective. You should let your GP know if the prescribed dose of PPIs doesn’t work. A stronger dose may be needed.

Surgery

Surgery is usually only recommended for a sliding hiatus hernia (hernias that move up and down, in and out of the chest area) if the problem fails to respond to lifestyle changes and medication.

You may also want to consider surgery if you have persistent and troublesome symptoms, but don’t want to take medication on a long-term basis.

Prior to surgery, you may need further investigations to check how well the oesophagus moves (manometry) and how much acid is being refluxed (24-hour oesopageal pH studies).

Laparoscopic nissen fundoplication (LNF)

A procedure called a laparoscopic nissen fundoplication (LNF) is one of the most common surgical techniques used to treat GORD and sliding hiatus hernias.

LNF is a type of keyhole surgery that involves making a series of small cuts in your abdomen. Carbon dioxide gas is used to inflate your abdomen to give the surgeon room to work in.

During LNF, the stomach is put back into the correct position and the diaphragm around the lower part of the oesophagus is tightened. This should prevent any acid moving back out of your stomach.

LNF is carried out under general anaesthetic, so you won’t feel any pain or discomfort. The surgery takes 60 to 90 minutes to complete.

After having LNF, you should be able to leave hospital after you’ve recovered from the effects of the general anaesthetic. This is usually within 2 to 3 days. Depending on the type of job you do, you should be able to return to work within 3 to 6 weeks.

For the first 6 weeks after surgery, it’s recommended that you only eat soft food, such as mince, mashed potatoes or soup. Avoid eating hard food that could get stuck at the site of the surgery, such as toast, chicken or steak.

Common side effects of LNF include difficulties swallowing (dysphagia), belching, bloating and flatulence.

These side effects should resolve over the course of a few months. However, in about 1 in 100 cases they can be persistent. In such circumstances, further corrective surgery may be required.

Para-oesophageal hiatus hernia

If you have a para-oesophageal hiatus hernia, where the stomach pushes up through the hole in the diaphragm next to the oesophagus, surgery may be recommended to reduce the risk of the hernia becoming strangulated (see complications of a hiatus hernia for more information).

symptoms, treatment, classification, causes, diagnosis and complications of the disease

Prices Popular questions

Hiatal hernia (HH) is a chronic disease in which the end of the esophagus, the cardia of the stomach, less often the intestinal loops are displaced through a weakened muscle ring. Pathology is accompanied by heartburn, pain in the solar plexus, hiccups. Since the symptoms are similar to other diseases of the gastrointestinal tract, the disease often goes unnoticed, and drugs for existing symptoms are selected incorrectly.

About the disease Classification Symptoms Causes Diagnosis Expert opinion Treatment Prevention Rehabilitation

About disease

Hernia of the esophagus (aka diaphragmatic) is a recurrent pathology. The mechanism of occurrence of characteristic symptoms is associated with the movement of the abdominal esophagus through the anatomical opening in the diaphragm into the chest cavity. Not only the esophagus and gastric walls, but also the omentum or intestinal loops can enter the hernial orifice. Their displacement in most cases is associated with an increase in pressure inside the abdominal cavity.

Diaphragmatic esophageal hernias are often detected in women and elderly patients. The probability of developing pathology in people under 40 is only 10%, while after 70 it is already 75%. There is also a dependence on lifestyle. Residents of large cities often face pathology due to a pronounced deficiency of fiber in the diet. This leads to disruption of intestinal motility, constipation and increased intra-abdominal pressure. Also increase the risk of diaphragmatic hernia the presence of diseases of the digestive system – gastritis, gastroduodenitis, esophagitis, ulcers or erosion.

Types of hiatal hernia

Classification of diaphragmatic hernias is based on their structure. Doctors take into account which part extends beyond the abdominal cavity.

sliding. On the back wall of the mediastinum, the sections of the esophagus and the initial section of the stomach (cardia) are displaced.
Paraesophageal. The bottom of the stomach passes through the opening, while the esophagus and cardia remain under the diaphragm.
Mixed. Combines features of both the first and second forms.

The type of hernia of the esophageal opening of the diaphragm depends not only on the clinic of pathology, but also on the methods of effective treatment.

Symptoms of hiatal hernia

Signs of a hernia of the esophagus may be absent for a long time. The patient’s condition changes dramatically if the protrusion reaches a large size. The first complaint is pain in the stomach. In this case, patients go to the doctor with suspected reflux (GERD). After the examination, a hernia of the esophageal opening of the diaphragm is determined, while most patients do not know what it is, how it is treated and what is dangerous.

Symptoms of esophageal hernia include:

pain in the stomach, heart, or left hypochondrium;
nausea and vomiting streaked with blood;
respiratory failure and oxygen deficiency, especially during sleep;
heartburn;
cough and sore throat;
eructation of sour contents;
visual bulging of the chest on the left.

The patient’s condition worsens immediately after a heavy meal, after physical exertion, and also when in an inclined position.

Causes of esophageal hernia

The development of esophageal hernia is associated with a decrease in the function of the ligamentous apparatus and muscles in the stomach, as well as an increase in pressure in the abdominal cavity. Provoking factors in the disease can be malnutrition, frequent constipation, prolonged cough, ascites, pregnancy, obesity, excessive exercise.

The development of the disease against the background of shortening of the esophagus is not excluded. Pathology is noted with heart defects, inflammatory lesions of the esophageal mucosa and injuries.

Diagnosis of esophageal hernia

Diagnosis of a hernia of the esophagus includes an examination by a gastroenterologist with a mandatory history taking, the appointment of instrumental and laboratory research methods. The main ways to detect pathology are x-rays and endoscopy. According to the results of endoscopy, there are no changes in the state of the esophagus in the area of the diaphragmatic ring. Less commonly, a specific bulging in the form of a circle is determined in this area. This is a characteristic sign of a hernial sac. On imaging, hyperemia (redness) of the mucous membrane is possible, indicating reflux or reflux of stomach contents into the lower esophagus.

Important information can be obtained from x-rays, which are carried out in three stages:

take a picture of the esophagus and stomach in a standing position;
the patient drinks a contrast agent (barium suspension), the radiography is repeated;
the patient is placed in a horizontal position with the head down and the picture is taken again.

In the absence of pathological processes at the third stage, there is no reflux of the contrast agent due to the locking mechanism of the cardiac part of the stomach, but with all types of hiatal hernias, an increase in the diameter of the hole is noted. Accordingly, nothing prevents the barium suspension from being thrown back.

Esophageal manometry is highly informative. The method allows to determine the state of the esophageal sphincter, its ability to relax and close, depending on the swallowing reflex. X-ray, ultrasound, manometry do not give a clear picture of this disease. But they help to make a differential diagnosis with other pathologies accompanied by similar symptoms.

Expert opinion

Treatment of hiatal hernia

Treatment of esophageal hernia begins with the use of conservative methods:

weight normalization;
avoiding restrictive clothing;
sleep in a half-sitting position;
fractional meals with increased fiber content in the diet;
normalization of gastric acidity by taking drugs to reduce it;
improvement of peristalsis and contractility of the stomach due to drugs.

Therapy is carried out over several weeks. Only in the absence of effect, the question of surgical intervention is considered. Also, the operation is indicated at a high risk of developing negative consequences of a hernia of the esophagus (development of cancer of the mucous membranes, tissue necrosis).

The surgeon’s tactics depend on the size and content of the hernial sac. Surgical intervention is performed under local anesthesia or under anesthesia by laparoscopic or abdominal method. The essence of the operation is to suture the enlarged opening of the diaphragm. Often, doctors additionally strengthen the tissues with a makeshift cuff from the stomach wall (fundoplication). With an extremely large weight of the patient, it is possible to simultaneously eliminate the esophageal hernia and bariatric surgery (resection or suturing of the stomach).

Esophageal hernia prevention

Prevention of hiatal hernia includes timely treatment of diseases of the digestive system and regular examination of patients at risk. You should visit a gastroenterologist and perform FGS of the esophagus and stomach once a year. It is also important to normalize body weight with its excess, as well as follow the principles of proper nutrition. The optimal regimen is to eat small meals 5-6 times a day. Spicy, fatty, fried foods, as well as alcoholic beverages must be excluded. Fiber must be present in the diet.

Patients who have undergone surgery and patients with hiatal hernia should always follow a heartburn-free diet and take medications prescribed by a doctor. The goal of prevention is to reduce the risk of recurrence and progression of the pathology.

Rehabilitation

After conservative treatment, rehabilitation is not required. It is enough to follow a diet and take drugs to normalize the level of acidity of gastric juice.

If surgery was performed, rehabilitation may take several weeks, depending on the chosen method of performing the operation. The first day after the transfer of the patient from the intensive care unit to the ward, hunger is shown. Next, the patient is transferred to a light diet with the most sparing products. Additionally, analgesics are prescribed to eliminate pain. In the future, an antireflux diet is constantly observed.

Sources

The author of the article

Senko Vladimir Vladimirovich
Head of the Center for Surgery and Oncology More than 23 years of experience

FAQ

Answered questions: Mikhailov Aleksey Gennadievich Surgeon, oncologist, mammologist, endocrine surgeon.

No, conservative treatment and proper nutrition are indicated at the initial stage.

Yes, coughing is one of the signs of illness. If respiratory diseases are all excluded, an endoscopic examination of the esophagus and stomach should be performed.

No, any restrictive clothing will have to be discarded. If this is not possible (dance activity), it is worth consulting a doctor.

The operation is performed if conservative therapy is ineffective, a large hernia is fixed in the esophagus, there is a risk of infringement or it has already occurred, there are complications of the disease (esophagitis, erosion, ulcers, dysplasia of the esophageal mucosa).

It is impossible to say unequivocally that this or that method of operation will be the best for hiatal hernia. The choice of method of intervention depends on the type of hernia, the severity of distal esophagitis, the presence of concomitant diseases, as well as data from instrumental and laboratory studies.

Article published: 09.12.2022
Last update: 05/19/2023