Hiatal hernia
Hiatal hernia is a defect in the diaphragm that permits a portion of the stomach to pass through the diaphragmatic opening into the chest. Three types of hiatal hernia can occur: sliding
hernia, paraesophageal (rolling) hernia, and mixed hernia, which includes features of both. (See Two types of hiatal hernia.)
hernia, paraesophageal (rolling) hernia, and mixed hernia, which includes features of both. (See Two types of hiatal hernia.)
In a sliding hernia, both the stomach and the gastroesophageal junction slip up into the chest, so that the gastroesophageal junction is above the diaphragmatic hiatus. In paraesophageal hernia, a part of the greater curvature of the stomach rolls through the diaphragmatic defect. Treatment can prevent such complications as strangulation of the herniated intrathoracic portion of the stomach.
Causes
Usually, hiatal hernia results from muscle weakening that’s common with aging and may be secondary to esophageal cancer, kyphoscoliosis, trauma, and certain surgical procedures. It may also result from certain diaphragmatic malformations that may cause congenital weakness.
In hiatal hernia, the muscular collar around the esophageal and diaphragmatic junction loosens, permitting the lower portion of the esophagus and the stomach to rise into the chest when intra-abdominal pressure increases (possibly causing gastroesophageal reflux). Such increased intra-abdominal pressure may result from ascites, pregnancy, obesity, constrictive clothing, bending, straining, coughing, Valsalva’s maneuver, or extreme physical exertion.
Incidence
A sliding hernia is 3 to 10 times more common than paraesophageal and mixed hernias combined. In fact, sliding hernias comprise 90% of hiatal hernias. The incidence of hiatal hernia is higher in women than in men (especially the paraesophageal type) and increases with age.
Signs and symptoms
Typically, a paraesophageal hernia produces no symptoms; it’s usually an incidental finding on barium swallow. Because this type of hernia leaves the closing mechanism of the cardiac sphincter unchanged, it seldom causes acid reflux and reflux esophagitis.
Symptoms result from displacement or stretching of the stomach and may include a feeling of fullness in the chest or pain that resembles angina pectoris. Even if it produces no symptoms, this type of hernia needs surgical treatment because of the high risk of strangulation.
A sliding hernia without an incompetent sphincter produces no reflux or symptoms and, consequently, doesn’t require treatment. When a sliding hernia does cause symptoms, they’re typical of gastric reflux (resulting from the incompetent lower esophageal sphincter [LES]) and may include the following:
