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GI & Advanced laparoscopic surgery

Hiatal Hernia

 

The esophagus enters the abdomen through the diaphragmatic hiatus. The hiatus is vulnerable to visceral herniation because it is directly subject to pressure stress between the abdomen and the chest.

Hiatus hernia is a condition involving herniation of the contents of the abdominal cavity, most commonly the stomach, through the diaphragmatic hiatus into the mediastinum.

 

Types

 Type I

Hernias are most common (95%),sliding hiatal hernias, where the gastroesophageal junction migrates above the diaphragm. The stomach remains in its usual position and the fundus remains below the gastroesophageal junction.

 Type II

Hernias are pure para-esophageal hernias (PEH); the gastroesophageal junction remains in its normal position but a portion of the fundus herniates through the diaphragmatic hiatus adjacent to the esophagus.

 Type III

Hernias are a combination of Types I and II, with both the gastroesophageal junction and the fundus herniating through the hiatus. The fundus lies above the gastroesophageal junction.

 Type IV

Hiatal hernias are characterized by the presence of a structure other than stomach, such as the omentum, colon or small bowel within the hernia sac.

 

Symptoms

Small hernias — Most small hiatal hernias cause no problems.

Large hernias — Larger hernias may cause the following signs and symptoms when stomach acids back up into your esophagus.

  • Heartburn
  • Belching
  • Chest pain
  • Nausea

These signs and symptoms tend to become worse when you lean forward, strain, lift heavy objects or lie down, and they can also worsen during pregnancy.

In rare cases, sometimes, the part of your stomach that protrudes into your chest cavity may become twisted (strangulated) or have its blood supply cut off, leading to:

  • Severe chest pain
  • Difficulty in swallowing (dysphagia)
  • Obstruction of your esophagus

 

 

Risk Factors

  • age 50 or older
  • obesity
  • smoking
  • congenital defects : most common cause of paraesophageal hernia in children, sometimes associated with other malformations

 

Diagnosis

Endoscopy: The clinical indications for endoscopy of the upper gastrointestinal tract include

  • symptoms typical of GERD but that are refractory to treatment
  • alarm signs (dysphagia, bleeding, weight loss, anemia), or
  • symptoms in patients older than 50 years.

Radiologic imaging: Hiatus hernia can be diagnosed by radiology of the upper gastrointestinal tract, albeit with poor sensitivity for mucosal complications. Radiology is usually indicated in the presurgical evaluation.

High resolution manometry and reflux monitoring: Functional esophageal testing using manometry (assessment of esophageal contractile function using an esophageal catheter) and reflux monitoring (assessment of reflux of gastric content into the esophagus using an esophageal catheter) is indicated when surgery is being considered to control symptoms of gastroesophageal reflux related to hiatal hernia.

pH testing: has limited relevance in the diagnosis of a hiatal hernia, but is critical to identify the presence of increased esophageal acid exposure in patients with sliding hiatal hernias that might benefit from antireflux surgery.

 

Complications

  • Bleeding and anemia
  • Reduced blood flow to stomach
  • GERD
  • Difficulty swallowing
  • Barrett’s esophagus
  • Esophageal Cancer

 

Treatment options

 Lifestyle modifications

    • Eat small meals
    • Avoid problem foods and alcohol
    • Limit fatty foods
    • Sit up after you eat
    • Don’t exercise immediately after eating
    • Lose Weight
    • Stop smoking
    • Elevate the head of your bed
    • Avoid tight fitting clothes

Medical approach:

Alleviation of the symptoms of GERD is the cornerstone for treatment of hiatus hernia. This is usually achieved indirectly with Proton pump inhibitors (PPIs). Histamine 2 receptor antagonists and antacids are alternatives to PPIs.

 

Surgical approach:

A few people with a hiatal hernia may need surgery. This is usually considered only when medications and lifestyle changes fail to relieve severe reflux symptoms, or if you have complications such as chronic bleeding or narrowing or obstruction of your esophagus.

Large hiatal hernias may also need repair if they cause symptoms such as shortness of breath, difficulty breathing or swallowing, or chest pain.

 

Laparoscopic fundoplication:

Currently, this is the standard procedure. The essential components of this technique are mobilization of the distal esophagus, reduction of the associated hiatus hernia, and either partial (Toupet 270°) or complete (Nissen 360°) fundoplication around the esophagus. With this procedure, the risk of major complications or death is about 1-2%.