As with almost all clinical pictures, hernia cannot be attributed to a single cause, but is rather an unfortunate concatenation of many factors. With age the tissue and muscles become weaker. The diaphragm is also a muscle.
When the muscles become weaker, the opening of the diaphragm also becomes looser and allows additional contents, such as the stomach, to pass more easily. Being overweight is another important factor in the development of diaphragmatic hernias, because especially when lying down, a great deal of pressure is exerted on the diaphragm and the organs, in this case the stomach, use weak points to avoid them. The process during pregnancy is similar.
A hernia can also develop if there is a strong increase in abdominal pressure, for example during pressing. In addition, congenital malformations can pose a risk. The transition between stomach and oesophagus usually has a certain angle, the so-called His angle.
If this angle is steeper, the stomach can slide more easily through the opening. Various diaphragmatic malformations also lead to congenital hernias. Most paraesophageal hernias are caused by such developmental disorders.
In many cases, the existence of an axial hiatus hernia is not known to the affected persons, since it usually does not cause any symptoms. Sometimes gastrointestinal sounds in the chest area can be heard when listening. In case of complaints such as heartburn, a gastroscopy can be performed, in which the hernia may be noticeable.
An X-ray examination with contrast media is also suitable for diagnosis. If gastroscopy is performed for other reasons, the hiatus hernia can be found as a chance finding and therefore does not necessarily need to be treated. The patient’s medical history is important, as the probability of relapse is very high in the case of previous hernias.
Symptoms of axial hiatus hernias
In many cases, axial hiatus hernias are completely asymptomatic, which means that the affected person has no symptoms. Common symptoms of hiatus hernias are heartburn and a feeling of pressure in the chest. As a result of the transition gliding up, the lower closure mechanism of the esophagus no longer functions and the stomach acid can flow up and cause heartburn, especially when lying down.
The feeling of pressure comes from the additional space in the chest cavity. If there are large parts of the stomach in the thoracic cavity, breathing difficulties can also occur due to the space requirement, as the stomach restricts the lungs. Swallowing difficulties are also a possible symptom, which occurs due to the narrowing of the stomach in the diaphragm opening.
In many patients, in addition to the hernia, gallstones and diverticulosis, i.e. small protrusions of the intestinal wall, are also present. Although the connection is not clear, there is a clear accumulation of these three diseases together and doctors refer to them as Saint-Trias. In rare cases there are incarcerations which disrupt the blood supply and thus lead to ulcers and bleeding in the stomach, which are accompanied by pain, nausea and anaemia.
These consequences are significantly more frequent in paraesophageal hernia. You can find more about the symptoms on our page Symptoms of a diaphragmatic herniaNormally the esophagus at the transition to the stomach forms a muscular ring at the transition to the stomach and thus prevents the backflow of gastric acid into the esophagus. This process is supported by the diaphragm at the point where the esophagus passes through.
However, when the transition between the esophagus and the stomach glides over the diaphragm, this support of the closing mechanism is missing. Especially when lying down, gastric acid backflows into the esophagus and causes heartburn. The mucous membrane of the oesophagus, unlike that of the stomach, does not have any protective measures against the body’s own acid.
The stomach acid attacks the mucous membrane and leads to inflammation and ulcers, which in extreme cases can become malignant tumours. A so-called reflux esophagitis is therefore in need of treatment. In most cases, acid inhibitors such as pantoprazole are given first, thus reducing the acid production of the stomach.
When diagnosing chest pain, a possible heart attack should always be ruled out for safety’s sake, as the acute symptoms may be similar. If no improvement is achieved by conservative therapy, surgical therapy should be considered. The axial hiatus hernia itself only causes stomach pain in rare cases.
However, those affected may suffer from reflux esophagitis and thus develop severe heartburn and chest pain. These can usually be controlled with acid blockers. Possible circulatory disorders can also trigger pain.
A circulatory disorder with subsequent death of parts of the stomach is very rare in axial hernia and is more likely to occur in paraesophageal hernia. In case of unclear chest pain a possible heart attack should always be excluded. In both forms of hiatus hernia, in extreme cases heart problems can occur, since large parts of the stomach represent a space requirement in the chest cavity and thus the heart may be constricted.
This leads to circulatory problems and also breathing difficulties. Those affected are usually operated on directly and monitored by intensive medical care. It is more common that the pain of reflux esophagitis is initially classified as a heart condition, as the acute pains are quite similar.
Bad breath is a frequent accompanying symptom of reflux esophagitis. Those affected often have to burp and the stomach acid can smell unpleasant. If ulcers already exist in the esophagus, these damaged areas of the mucous membrane can also cause severe bad breath. This bad breath comes from the oesophagus and therefore cannot be prevented by intensive oral hygiene. Because of its social component, bad breath can be a severe limitation for those affected and can therefore also be an indication for surgery.