Brief overview
- Symptoms: Symptoms depend on the particular type of hiatal hernia and do not occur in all cases.
- Treatment: Axial hernias usually do not require surgery. However, surgery should always be considered for the other hiatal hernias.
- Causes and risk factors: a diaphragmatic hernia is either congenital or develops during life. Risk factors for an acquired diaphragmatic hernia include obesity and age.
- Course of the disease and prognosis: The prognosis depends on the particular type of diaphragmatic hernia and the possible complications. In most cases, it is a sliding hernia and the prognosis is good.
- Prevention: To reduce the risk of diaphragmatic hernia, it is advisable, among other things, to reduce excess weight and avoid physical inactivity.
What is a diaphragmatic hernia?
The dome-shaped diaphragm consists of muscle and tendon tissue. It separates the thoracic cavity from the abdominal cavity. It is also considered the most important respiratory muscle.
The diaphragm has three large openings:
In front of the spine is the so-called aortic slit, through which the main artery (aorta) and a large lymphatic vessel pass.
The esophagus passes through the oesophageal hiatus, the third major hole, and opens into the stomach just below the diaphragm. The esophageal opening forms a direct connection between the chest and abdomen. Since the muscle tissue at this point is comparatively loose, a hiatal hernia occurs primarily here.
Hiatal hernias are subdivided according to the origin and location of the parts spilling into the chest cavity.
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Hernia type I |
Axial hiatal hernia |
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Hernia type II |
Paraesophageal hiatal hernia A portion of the stomach of varying size passes next to the esophagus into the thoracic cavity. However, the entrance of the stomach remains below the diaphragm – in contrast to the type I hernia. |
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Type III hernia |
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Hernia type IV |
This is a very large hernia of the diaphragm in which other abdominal organs, such as the spleen or colon, also spill into the chest cavity. |
Extrahiatal diaphragmatic hernia
The common term diaphragmatic hernia usually refers to the displacement of organs through the esophageal slit (hiatus oesophageus), therefore also called hiatal hernia.
For example, there is a hole (Morgagni) at the junction with the sternum through which loops of intestine are preferentially displaced (Morgagni hernia, parasternal hernia). And a triangular-shaped gap in the posterior part of the muscular diaphragm (Bochdalek gap) may also cause a hernia.
Frequency
If the hernia occurs due to an undeveloped diaphragm, it is the congenital form. Doctors find a diaphragmatic defect in about 2.8 out of 10,000 births. This develops in the eighth to tenth week of pregnancy. Exactly how this developmental disorder occurs has not yet been conclusively clarified.
How can you recognize a diaphragmatic hernia?
Whether you have symptoms of a diaphragmatic hernia usually depends on the type and extent of the hernia in question.
In type I diaphragmatic hernia, there are usually no symptoms. Patients often report heartburn and pain behind the breastbone or in the upper abdomen. People with a diaphragmatic hernia may also experience a chronic cough.
However, these are not so much diaphragmatic hernia symptoms; rather, the symptoms are due to concomitant reflux disease.
In addition, the esophagus opens very steeply into the stomach. This circumstance makes reflux even more difficult.
The healthy diaphragm supports this process, which is why a hernia of the diaphragm increases the risk of reflux. Eventually, the upper end of the diaphragmatic hernia narrows and a so-called Schatzki ring develops.
As a result, patients suffer from dysphagia or steakhouse syndrome: a piece of meat gets stuck and blocks the esophagus.
Symptoms of paraesophageal hiatal hernia
At the beginning of a type II hiatal hernia, there are usually no symptoms. As the condition progresses, patients find it difficult to swallow.
In some patients, stomach contents flow back into the esophagus. Especially after eating, patients often experience an increased feeling of pressure in the heart area and circulatory problems.
As in the case of an axial diaphragmatic hernia, the tissue of the stomach wall may be damaged. Under certain circumstances, the resulting defects bleed unnoticed.
Approximately one third of all type II hernias are therefore first noticed due to chronic anemia. The remaining two-thirds are found by physicians by chance or become apparent through swallowing difficulties. If a hiatal hernia causes severe symptoms, the hernia sac is usually very large. In extreme cases, the entire stomach is displaced into the chest cavity.
Symptoms in other diaphragmatic hernias
Symptoms in extrahiatal diaphragmatic hernias are similar. Some patients have no symptoms at all, in others these diaphragmatic hernias are more complicated.
This is because, as with hiatal hernias, the contents of the hernia sac – intestinal loops or other abdominal organs – may die here, and toxins are released that are life-threatening to the body.
How can a diaphragmatic hernia be treated?
The goal of any diaphragmatic hernia treatment is to relieve symptoms and prevent complications. Thus, a diaphragmatic hernia that does not cause any symptoms does not necessarily need to be treated.
If treatment of the axial hiatal hernia with medication does not lead to the desired success or if the reflux disease is already chronic, surgery is sometimes necessary. The same applies to all other diaphragmatic hernias: they are usually treated surgically to avoid complications or late effects.
Diaphragmatic hernia surgery
The aim of the operation is to return the organs to their original position in the abdominal cavity and fix them there.
In the process, the diaphragmatic hernia that has passed through into the thoracic cavity is properly repositioned in the abdominal cavity. Subsequently, the hernia gap is narrowed and stabilized (hiatoplasty). In addition, the gastric fundus, i.e. the dome-shaped upper bulge of the stomach, is sutured to the left lower side of the diaphragm.
If the goal of the hiatal hernia surgery is only to correct the reflux disease, the so-called fundoplicatio according to Nissen is performed. The surgeon wraps the gastric fundus around the esophagus and sutures the resulting sleeve. This increases the pressure on the lower esophageal sphincter at the mouth of the stomach and gastric juice hardly flows upward.
Plastic meshes
How does a diaphragmatic hernia develop?
A diaphragmatic hernia is divided into congenital and acquired forms. The latter has different causes and dimensions. Congenital diaphragmatic hernias, on the other hand, usually develop due to a maldevelopment of the diaphragm.
Developmental disorders during the embryonic period
In the second phase, the muscle fibers grow in. If a disruption occurs during this time (fourth to twelfth week of pregnancy), a defect develops in the diaphragm.
These gaps may cause abdominal parts to shift into the thorax. Since organ sheaths, such as the peritoneum, are not yet formed at the beginning, the organs lie exposed in the thoracic cavity.
Risk factor body position
Axial diaphragmatic hernia is also called a sliding hernia. The herniated abdominal contents slide back and re-enter the chest cavity. Thus, it slides back and forth between the chest cavity and the abdominal cavity.
The stomach sections shift mainly when the patient is lying down or when the upper body is lower than the lower abdomen. If affected persons stand upright, the displaced portions return to the abdominal cavity following the force of gravity.
Risk factor pressing
The risk thus also increases with forced rapid exhalation, abdominal clenching and during bowel movements.
Risk factors severe obesity and pregnancy
Similar to pressing, obesity and pregnancy increase the risk of diaphragmatic hernia. An excessive amount of fatty tissue in the abdomen (peritoneal fat) increases pressure on the organs, especially when lying down.
Risk factor age
Age apparently plays a role in the development of diaphragmatic hernias. For example, gleithernias can be detected in 50 percent of people over the age of 50.
Experts believe that the connective tissue of the diaphragm weakens and the esophageal slit widens (bulges). In addition, the ligaments between the stomach and diaphragm loosen where the esophagus joins the stomach.
Diagnosis and examination
Many hiatal hernias are discovered by chance when the doctor performs an X-ray or a check gastroscopy. This is usually done by a specialist in gastroenterology in the field of internal medicine, and sometimes by a lung specialist (pulmonologist).
Some patients suffer from heartburn with diaphragmatic hernia and consult their family doctor with such complaints.
Medical history (anamnesis) and physical examination
In this context, already known, previous diaphragmatic hernias of the patient are particularly important. Since traumatic events such as surgery or an accident may also damage the diaphragm, such information plays a decisive role in the diagnosis.
The physician will therefore also go into the previous medical history. If intestinal loops are displaced during the diaphragmatic hernia, the physician may hear intestinal sounds above the chest with a stethoscope.
Further examinations
For the exact classification and planning of a diaphragmatic hernia treatment, the physician performs further examinations.
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Method |
Explanation |
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X-ray |
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Breast swallow, contrast medium |
In this examination, the patient swallows a contrast medium gruel. The physician then performs an X-ray. The mush, which is largely impermeable to X-rays, is clearly visible and shows possible constrictions that he does not pass. Alternatively, it may show up above the diaphragm in the chest cavity in the area of the diaphragmatic hernia. |
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Gastroscopy (esophago-gastro-duodenoscopy, ÖGD) |
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Feeding tube pressure measurement |
The so-called esophageal manometry determines the pressure in the esophagus and thus provides information about possible movement disorders caused by a diaphragmatic hernia. |
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Magnetic resonance imaging (MRI) and computed tomography (CT). |
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Ultrasound (of the fetus) |
In the case of a congenital diaphragmatic hernia, a fine ultrasound of the unborn child will show relatively early whether surgery is necessary. The doctor measures the ratio of lung area to head circumference to estimate the extent of the diaphragmatic hernia. |
Course of the disease and prognosis
About 80 to 90 percent of gleithernias remain symptom-free and do not require therapy. If surgery is nevertheless necessary, about 90 percent of patients with diaphragmatic hernia are symptom-free afterwards.
Complications
The course of a diaphragmatic hernia is less favorable if complications occur. For example, if the stomach or the contents of the hernia sac twist, their blood supply is cut off. Consequently, the tissue becomes inflamed and dies. Toxins released as a result are distributed throughout the body and severely damage it (sepsis).
In these cases, surgery is performed quickly and the affected person is cared for in an intensive care unit. In addition, bleeding from tissue damage causes chronic anemia.
However, because most hernias are harmless and symptom-free sliding hernias, a diaphragmatic hernia usually runs its course without complications with a good prognosis.
Prevention
It is also advisable not to eat anything directly before going to bed. Especially in the case of a known sliding hernia, a slightly elevated upper body at night prevents abdominal organs from sliding up into the chest cavity again. Patients also experience less heartburn as a result, thus reducing the risk of reflux disease and its consequences.
