A hiatal hernia, popularly known as a diaphragmatic hernia, occurs when part of the stomach pushes through the diaphragm into the chest. In most cases, a hiatal hernia will go undetected and cause no problems. In more severe cases, treatment up to and including surgery may be needed.
What is hiatal hernia?
The diaphragm has a small opening (hiatus) through which the lower part of the esophagus opens into the stomach below the diaphragm. In the most common cases (90-95%) of a hiatal hernia, the upper stomach moves through the diaphragm into the chest cavity (sliding hernia or axial hiatal hernia), causing the diaphragm to no longer close the esophagus and stomach acid to flow back (reflux). In the so-called paraesophageal hiatal hernia, part of the stomach pushes through the hiatus and, in the worst case, lies completely in the chest cavity above the diaphragm. Other types of hiatal hernia are mostly milder forms and cause little discomfort. The likelihood of hiatal hernia increases with age, affecting approximately 60% of all individuals aged 50 years or older.
Causes
The causes of hiatal hernia are not fully understood. Pressure on the abdomen is thought to be the main factor. The diaphragm is a large dome-shaped muscle that separates the chest cavity from the abdomen. Hiatal hernia occurs when the muscle tissue around the opening for the passage of the esophagus to the stomach becomes fatigued. This can be caused directly by injury to the diaphragm, but also by anatomical abnormalities (e.g., hiatus that is too large). A persistent strong pressure on the surrounding muscles, is caused, for example, during coughing, strong vomiting, pregnancy or straining during defecation, as well as lifting heavy objects. Increasing age and obesity are other risk factors for hiatal hernia.
Symptoms, complaints, and signs
Depending on the type of hiatal hernia, different symptoms and signs may occur. Axial sliding hernia usually progresses without definite signs. Some sufferers have the typical symptoms of reflux disease. There is heartburn, belching of air, difficulty swallowing and regurgitation of food remnants. In paraesophageal hernia, the disease takes a rapid and usually severe course. In the first stage, there are usually no symptoms. In the uncomplicated stage, those affected suffer from belching and an increasing feeling of pressure in the area of the heart. The symptoms increase after eating and become more severe as the disease progresses. In the complication stage, serious complications can occur, for example bleeding, incarceration or severe stomach pain. In severe cases, a gastric ulcer forms, which may be manifested by stomach cramps and severe malaise. Furthermore, a hiatal hernia can lead to anemia and associated poor performance, pallor and palpitations. Acute bleeding may also occur in the final stage of the disease. However, life-threatening complications are rare. Externally, a hiatal hernia is not recognizable. However, sweating, pale skin and sunken eyes indicate a condition that needs to be investigated and clarified.
Diagnosis and course
Heartburn in hiatal hernia
Hiatal hernia resembles many diseases in its symptoms and therefore is rarely diagnosed in a direct way. For example, a diseased person may suffer from dull chest pain, shortness of breath (effect of the hernia on the diaphragm), palpitations (due to irritation of the vagus nerve), or difficulty swallowing. In most cases, a hiatal hernia itself will cause little discomfort. Pain and discomfort are often caused by the reflux of stomach acid, air or bile caused by a hiatal hernia (heartburn). Diagnosis of a hiatal hernia typically involves prompted testing to determine the cause of heartburn or pain in the upper abdomen. This may be done using an x-ray of the upper digestive tract with test fluid or an endoscopy, in which a thin tube with a light and video camera (endoscope) is passed into the stomach.
Complications
A hiatal hernia can result in various complications. It is not uncommon for an axial sliding hernia, also called a sliding hernia, to cause reflux of stomach acid.This in turn creates the risk of ulcers developing on the esophageal mucosa. In some cases, these ulcerations also cause bleeding. If a horizontal position is assumed while sleeping, in severe cases the stomach contents may flow up toward the esophagus. Sometimes this causes the patient to inhale the stomach contents or suffer from hoarseness. In addition, bronchial asthma may be exacerbated. Complications from a paraesophageal hernia are considered to be particularly unpleasant in the case of a hiatal hernia. If the stomach twists in the chest cavity and the diaphragmatic gap narrows, this makes it difficult to transport food further. This passenger disorder becomes noticeable through swallowing difficulties or vomiting in the morning hours. If it is a large hiatal hernia, it is conceivable that the upper part of the stomach becomes trapped and therefore bleeding occurs. Because of the chronic blood loss, anemia (anemia) is imminent. Dangerous complications of diaphragmatic hernia include circulatory problems in the trapped portion of the stomach. This process sometimes leads to serious sequelae such as a perforation of the stomach or peritonitis, which can be life-threatening. Complications can also arise during hiatal hernia surgery. These are mostly flatulence, injury to the visceral nerve and postoperative bleeding.
When should you go to the doctor?
If the affected person repeatedly suffers from heartburn or regularly has to burp uncomfortably, it is advisable to ask a doctor to clarify the symptoms. Complaints of the swallowing act are considered unusual. If the food has already been sufficiently crushed in the mouth, swallowing complaints should be examined by a doctor. If there is a refusal to take in food or liquids due to the discomfort, a physician is needed. If there is a feeling of internal dryness, there is cause for concern, as the patient may be at risk of dehydration and a life-threatening condition. In severe cases, an emergency physician must be called. If there is pain in the stomach or abdominal region, it is advisable to consult a physician. Painkilling medications should always be taken only in consultation with a medical professional. Side effects may occur that contribute to further deterioration of health. If the affected person has to regurgitate regularly ingested food in a reflexive feeling, this is unusual. The observation should be medically clarified and treated. If there are heart problems, an elevated pulse or increased heart activity, a visit to the doctor is advised. If there is sleep disturbance, sweating, or a general feeling of illness, a doctor is needed. If bleeding starts during bowel movements or urination, a medical examination should be initiated immediately.
Treatment and therapy
In most cases of hiatal hernia, patients experience no symptoms and no action is required. Treatment is primarily oriented toward reducing symptoms caused by hiatal hernia. Medications used are intended to neutralize stomach acid (antacids), reduce acid production (H-2 receptor blockers), or heal damaged tissue. In a small number of conditions, a hiatal hernia may require surgery. This is especially true for emergencies and patients who cannot be helped by medications. Surgery is especially recommended in cases of gastroesophageal hiatal hernia because chronic reflux can severely damage the esophagus and, in the worst cases, lead to esophageal cancer. Surgery involves pulling the stomach back into the lower abdomen and reducing the opening in the diaphragm. Lifestyle changes can also help relieve the symptoms of a hiatal hernia. Small meals spread throughout the day and a generally healthy lifestyle without alcohol are basic recommended measures. Symptomatic patients should sleep with their head elevated and avoid a lying position immediately after meals. Other recommendations for living with hiatal hernia include stress-reducing relaxation techniques and reducing obesity.
Outlook and prognosis
The outlook after a hiatal hernia can be considered very good. In more than three quarters of all cases, no therapy is necessary at all. Then physicians speak of gleithernias. They proceed without any complaints.Otherwise, the characteristic symptoms can be remedied with the help of medication. If surgery is performed, 90 percent of patients can subsequently continue to live without symptoms. In this context, the scientific situation can be classified as favorable. Newborns represent a risk group. Their lung volume is often limited. If an operation has to be performed, it is not uncommon for every second infant to die. The outlook for patients with a recurrence of the hiatal hernia is also rather unfavorable. However, this rarely happens. The tissue condition is also unsuitable in very few cases. In such cases, not all symptoms can be corrected. The hiatal hernia must go well during the surgical procedure. If complications arise, severe damage to the body often comes to light. Inflamed tissues and released toxins are only some of the negative consequences. As a consequence, normal participation in everyday life is no longer possible. Many affected individuals die shortly after such surgical therapy.
Prevention
Because a hiatal hernia is caused primarily by increased pressure in the abdomen, heavy lifting or other mechanical impact should be avoided. To counteract internal stress, care should be taken to maintain healthy intestinal flora to prevent constipation.
Aftercare
Provided that conservative treatment by means of medicinal acid inhibition with proton pump inhibitors has been successful or surgical therapy has been performed after recurrent reflux esophagitis and the patient is symptom-free and symptomless, no postoperative treatments are necessary. Repeated follow-up examinations can also be omitted if the patient is free of symptoms and the previous symptoms are absent. A single check-up by the surgeon is usually sufficient. However, if reflux symptoms or associated reflux esophagitis occur, a repeat upper endoscopy, manometry and pH-metry is recommended. Immediately after hiatoplasty, the transition zone between the esophagus and the cardia of the stomach is still swollen and irritated. Therefore, it is recommended to avoid solid food for the first few days after the procedure. Since surgical therapy significantly narrows the lower esophageal closure compared to the preoperative situation, minimal swallowing difficulties may remain as permanent complaints, as well as mild gastrointestinal symptoms (flatulence, diarrhea, restrictions or inhibition of vomiting or belching). To prevent these secondary complaints, attention should be paid to diet postoperatively and especially during the recovery period. It is recommended to optimize the diet with regard to personal intolerances and any other factors (digestibility, consistency) and, in addition, to allow enough time for food intake, to chew thoroughly, and to perform fluid and food intake separately.
Here’s what you can do yourself
Parallel to medical treatment, a hiatal hernia can be treated by yourself by means of various tips and measures. Above all, a change in lifestyle habits helps to alleviate the symptoms. A healthy and balanced diet without alcohol, caffeine and other stimulants is recommended. Since a hiatal hernia is often triggered by too much stomach acid, acid-producing foods (e.g. salt, sugar, dairy products and fried foods) should be avoided. Alkaline products such as cucumbers, celery, carrots, grapes and red fruits are suitable. Food intake should be in small meals spread throughout the day. Overweight individuals need to reduce their body weight in the long term to correct diaphragmatic hernia. Furthermore, the avoidance of stress applies, which can be achieved, for example, through targeted relaxation measures. Affected persons should also sleep with their head elevated and avoid lying down after meals if possible. Furthermore, medications such as aspirin should be avoided, as these lead to an increased PH value. Drugs containing estrogen or progesterone can weaken the hiatus muscles and should therefore also not be taken. If the symptoms do not subside despite the above measures, it is best to consult a doctor.
