my mess/ms: Hiatus hernia

A hiatus hernia or hiatal hernia is the protrusion (or herniation) of the upper part of the stomach into the thorax through a tear or weakness in the diaphragm. Hiatus hernias often result in heartburn but may also cause chest pain or pain with eating.^[1]
The most common cause is obesity. The diagnosis is often by endoscopy or medical imaging.^[1]
A hiatus hernia may be treated with lifestyle changes such as raising the head of the bed, weight loss, and adjusting eating habits. Medications such as H2 blockers or proton pump inhibitors may help. If the symptoms do not improve with medications the surgery known as laparoscopic fundoplication may be an option.^[1] It is not known how commonly hiatus hernias occur with estimates in North America varying from 10 to 80%.^[1]

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Signs and symptoms[edit]

Hiatal hernia has often been called the "great mimic" because its symptoms can resemble many disorders. For example, a person with this problem can experience dull pains in the chest, shortness of breath (caused by the hernia's effect on the diaphragm), heart palpitations (due to irritation of the vagus nerve), and swallowed food "balling up" and causing discomfort in lower esophagus until it passes on to stomach.
In most cases however, a hiatal hernia does not cause any symptoms. The pain and discomfort that a patient experiences is due to the reflux of gastric acid, air, or bile. While there are several causes of acid reflux, it does happen more frequently in the presence of hiatal hernia.
For newborn the presence of Bochdalek hernia can be recognised^[2] from symptoms such as difficulty breathing^[3] fast respiration, increased heart rate.^[4]

Risk factors[edit]

The following are risk factors that can result in a hiatus hernia.^{[citation needed]}

Increased pressure within the abdomen caused by:
- Heavy lifting or bending over
- Frequent or hard coughing
- Hard sneezing
- Violent vomiting
- Straining
- Stress

Diagnosis[edit]

The diagnosis of a hiatus hernia is typically made through an upper GI series, endoscopy or high resolution manometry.

A large hiatus hernia on X-ray marked by open arrows in contrast to the heart borders marked by closed arrows
Upper GI endoscopy depicting hiatus hernia
A hiatus hernia as seen on CT

Classification[edit]

Schematic diagram of different types of hiatus hernia. Green is the esophagus, red is the stomach, purple is the diaphragm, blue is the HIS-angle. A is the normal anatomy, B is a pre-stage, C is a sliding hiatal hernia, and D is a paraesophageal (rolling) type.

Three types of esophageal hiatal hernia are identified:
type I (sliding) hernia: characterized by an upward herniation of the cardia and GE junction in the posterior mediastinum. The most common type of Hiatal hernias (C).^[5]
type II (rolling or paraesophageal) hernia (PEH): characterized by an upward herniation of the gastric fundus alongside a normally positioned cardia. The GE junction is in its normal place (D).
type III (combined sliding-rolling or mixed) hernia: characterized by an upward herniation of both the cardia and the gastric fundus.
type IV hiatal hernia: is declared in some taxonomies, when an additional organ, usually the colon, herniates as well.
The end stage of type I and type II hernias occurs when the whole stomach migrates up into the chest by rotating 180° around its longitudinal axis, with the cardia and pylorus as fixed points. In this situation the abnormality is usually referred to as an intrathoracic stomach.

Treatment[edit]

In most cases, sufferers experience no discomfort and no treatment is required. If there is pain or discomfort, 3 or 4 sips of room temperature water will usually relieve the pain. However, when the hiatal hernia is large, or is of the paraesophageal type, it is likely to cause esophageal stricture and discomfort. Symptomatic patients should elevate the head of their beds and avoid lying down directly after meals. If the condition has been brought on by stress, stress reduction techniques may be prescribed, or if overweight, weight loss may be indicated. Medications that reduce the lower esophageal sphincter (LES) pressure should be avoided. Antisecretory drugs like proton pump inhibitors and H₂ receptor blockers can be used to reduce acid secretion.
Where hernia symptoms are severe and chronic acid reflux is involved, surgery is sometimes recommended, as chronic reflux can severely injure the esophagus and even lead to esophageal cancer.
The surgical procedure used is called Nissen fundoplication. In fundoplication, the gastric fundus (upper part) of the stomach is wrapped, or plicated, around the inferior part of the esophagus, preventing herniation of the stomach through the hiatus in the diaphragm and the reflux of gastric acid. The procedure is now commonly performed laparoscopically. With proper patient selection, laparoscopic fundoplication recent studies have indicated low complication rates, quick recovery, and relatively good long term results.^[6]^[7]^[8]^[9]^[10]
Complications include gas bloat syndrome, dysphagia (trouble swallowing), dumping syndrome, excessive scarring, and rarely, achalasia. The procedure sometimes fails over time, requiring a second surgery to make repairs.

Epidemiology[edit]

Incidence of hiatal hernias increases with age; approximately 60% of individuals aged 50 or older have a hiatal hernia.^[11] Of these, 9% are symptomatic, depending on the competence of the lower esophageal sphincter (LES). 95% of these are "sliding" hiatus hernias, in which the LES protrudes above the diaphragm along with the stomach, and only 5% are the "rolling" type (paraesophageal), in which the LES remains stationary but the stomach protrudes above the diaphragm. People of all ages can get this condition, but it is more common in older people.
According to Dr. Denis Burkitt, "Hiatus hernia has its maximum prevalence in economically developed communities in North America and Western Europe ... In contrast the disease is rare in situations typified by rural African communities."^[12] Burkitt attributes the disease to insufficient dietary fiber and the use of the unnatural sitting position for defecation. Both factors create the need for straining at stool, increasing intraabdominal pressure and pushing the stomach through the esophageal hiatus in the diaphragm.^[13]