What is Hiatal Hernia?
A hiatal hernia is a health condition where the upper part of the stomach or another internal organ pushes through an opening in the diaphragm, a muscle that aids in breathing. Normally, the esophagus or food pipe passes through a small hole in the diaphragm, called a hiatus, to connect to the stomach. This joining point is referred to as the gastroesophageal junction (GEJ). But if a hiatal hernia is present, the stomach squeezes through this hole and moves into the chest area. This can weaken the lower esophageal sphincter (LES), a valve-like muscle at the junction, allowing stomach contents and acid to flow back into the esophagus. It’s the primary cause of acid reflux, a condition also known as gastroesophageal reflux disease (GERD).
Small hiatal hernias often don’t present any symptoms and can usually be managed with medication. However, large hiatal hernias often necessitate surgery.
There are four types of hiatal hernias. Type I, which accounts for more than 95% of cases, is when the GEJ itself moves upward to the hiatus. Type II is when a part of the stomach shifts parallel to the esophagus into a region called the mediastinum. Type III is a combination, where both the GEJ and a piece of the stomach have moved into the mediastinum. Lastly, Type IV is when not only the stomach but also another organ, like the colon, small intestine, or spleen, pushes into the chest area.
What Causes Hiatal Hernia?
Hiatal hernias can either be present at birth or develop over time. They are more common in older people. As we age, our muscles can become weaker and less flexible, which can lead to the development of a hiatal hernia. This can cause the upper part of the stomach to stay above the diaphragm, its normal position, even after swallowing.
There can be other factors that contribute to the development of a hiatal hernia too. For example, having too much pressure in the abdomen can make a person more prone to getting a hiatal hernia. This can happen due to obesity, pregnancy, long-term constipation, and a certain type of lung disease called chronic obstructive pulmonary disease (COPD).
Additional factors such as previous injuries, getting older, having undergone certain surgeries, or even genetics can also increase the risk of developing a hiatal hernia.
Risk Factors and Frequency for Hiatal Hernia
Hiatal hernias become more common as people get older. They are found in 55%-60% of people over the age of 50, but only around 9% of these individuals experience symptoms. This largely depends on the kind of hiatal hernia and how well the lower part of the esophagus is functioning. Different types of hiatal hernias exist, but the most common one is the type I sliding hiatal hernia. Another type, the type II paraesophageal hernia, which is where the stomach sticks out above the muscle separating the chest and abdomen, is less common and makes up about 5% of hiatal hernias. Women are more likely to have hiatal hernias, possibly because pregnancy increases the pressure in the abdomen. These hernias are often seen in Western Europe and North America, but they are rare in rural parts of Africa.
Signs and Symptoms of Hiatal Hernia
A hiatal hernia is frequently detected due to symptoms of gastroesophageal reflux disease (GERD), which is commonly associated with heartburn and occasional food regurgitation. While heartburn is the primary symptom in these cases, patients may also exhibit seemingly unrelated issues such as a chronic cough or asthma. The acknowledgment of regurgitation, as well as these extra-esophageal symptoms, could indicate the progression of the disease, it should be clarified, though, that not everyone with regurgitation is having GERD. It’s also important to note whether the regurgitated food is digested or not.
Regurgitating undigested food might signal a different health issue like achalasia or a diverticulum. Difficulty swallowing or ‘dysphagia’ is another symptom that typically arises when the disease is quite advanced, which could be due to a physical blockage. This could suggest other health issues, such as a peptic stricture, a growth, diverticula, or a primary motor disorder, are present. It’s worth noting that a physical check-up rarely confirms the diagnosis in patients with a hiatal hernia and GERD. An important part of the evaluation process is to check the supraclavicular lymph nodes. If they’re abnormal in a patient experiencing heartburn and dysphagia, it could be a signal of esophageal or stomach cancer.
Testing for Hiatal Hernia
Should a patient be considered for surgery, certain preparatory evaluations are critical to both confirm the diagnosis and plan for the surgical procedure. Various tests are also used to rule out other possible conditions. These might include:
Endoscopy: This is a crucial step for patients with symptoms of Gastroesophageal Reflux Disease (GERD) and suspected hiatal hernia who may need surgery. An endoscopy can help determine if other issues like tumors are present, or if there is damage to the esophagus.
Manometry: This test can help identify if the patient has primary motility disorders like achalasia, which often mimic reflux symptoms. Patients with primary motility disorders might need a different type of surgical procedure known as partial fundoplication, rather than the normal procedure, called Nissen.
pH monitoring: This test checks for acid reflux and is considered the most reliable method for diagnosing this condition. During this 24-hour test, a probe is placed within the patient’s body to measure the amount of acid exposure. The results are represented as a DeMeester score. A score of 14.7 or above usually signifies significant acid reflux.
Esophagography: This test can provide essential information about the structure of the esophagus and upper part of the stomach. It can reveal anatomic abnormalities like tumors or strictures (narrowing of the body passage), which could affect the course of treatment or surgery.
Treatment Options for Hiatal Hernia
Treatment for hiatal hernias involves considering the type and severity of the hernia and its symptoms. If patients show typical signs of GERD, a condition where stomach acid frequently flows back into the tube connecting the mouth and stomach, they would usually start by taking a higher dosage of a proton pump inhibitor (PPI) – a type of drug that lowers the amount of acid produced in the stomach. If this approach doesn’t relieve symptoms, doctors may suggest a more thorough examination to decide the next steps.
Ever since PPIs were introduced, their use has altered when surgical treatment becomes necessary. Usually, patients with serious damage to the esophagus, such as ulcers or strictures (areas of narrowing), or Barrett’s mucosa (a condition where the tissue lining the esophagus changes to tissue resembling the lining of the intestine) might be considered for surgery. Also, surgery might be an option for those who have symptoms for a long time or whose symptoms don’t completely go away even with medication.
Given recent advances in less invasive surgical techniques for GERD treatment, the expense of surgery has dropped. As a result, surgical treatment might be the first choice for patients expected to live longer than 8 years who would otherwise need lifetime drug therapy because of a faulty LES, a muscle at the bottom of the esophagus that acts like a valve between the esophagus and stomach.
Another type of hiatal hernia, called a paraesophageal hernia, may result in a severe condition known as gastric volvulus in which the stomach twists upon itself. This situation needs immediate surgical attention. It’s generally recommended that all symptomatic paraesophageal hernias, as well as large asymptomatic hernias in otherwise healthy patients under 60, be surgically repaired.
There are several surgical procedures employed to treat hiatal hernias. One is called Nissen fundoplication, a procedure in which the upper part of the stomach is wrapped around the lower end of the esophagus to strengthen the LES. This is done carefully to avoid making the wrap too tight.
On the other hand, when there is poor movement in the esophagus, a partial fundoplication procedure is usually chosen. Two such procedures called the Dor and Toupet involve wrapping around 180 to 250 degrees of the upper part of the stomach around the esophagus. These partial wraps are believed to help prevent blockages in the esophagus when its ability to move is compromised. The Dor technique is more likely to be used in cases of achalasia (a condition where the esophagus does not properly move food towards the stomach), while the Toupet procedure would be employed if motility were an issue.
What else can Hiatal Hernia be?
When a patient shows symptoms of GERD (Gastroesophageal reflux disease), it can be challenging for doctors to identify the exact cause due to a vast number of potential conditions sharing similar symptoms. This is why in-depth medical testing is crucial before beginning treatment.
GERD typically causes heartburn, which feels like a sharp or burning pain in the upper abdomen. This pain usually doesn’t spread to the back or feel like pressure. Understanding these features aids doctors in differentiating GERD from other potential illnesses like pancreatitis or heart conditions.
GERD can also cause symptoms related to the respiratory system, like voice changes or breathing difficulties. Identifying the root cause of these symptoms can be tricky, as they may also occur due to issues with the esophagus, stomach and lung diseases, or even cancer in the stomach or esophagus. Therefore, if a patient presents these symptoms and initial tests don’t provide conclusive results, doctors often need to investigate further, possibly involving a lung specialist to help get to an accurate diagnosis.
What to expect with Hiatal Hernia
The effectiveness of hiatal hernia surgery is determined by how well it alleviates symptoms, reduces acid exposure in the esophagus, minimizes complications, and avoids the need for additional surgeries. In one research study, they monitored 100 patients who went through anti-reflux surgery for a period of ten years. After a decade, there was a reduction of symptoms in 90% of the cases.
The overall success rates of these surgeries have improved over the last two decades because of advancements in surgical techniques and increased experience. Particularly in centers that perform a high number of similar procedures, there has been a noticeable rise in symptom relief and a decline in complications arising during or after the surgery.
Possible Complications When Diagnosed with Hiatal Hernia
Complications from surgery are usually minor and aren’t directly because of the surgery itself. The risk of dying within 30 days from an antireflux surgery is quite low – only about 0.19%. There are, however, a few complications that are specifically related to this type of surgery:
- Pneumothorax, or a collapsed lung: this is the most common complication that may occur during the surgery. Happily, it’s seen in fewer than 2% of patients.
- Injuries to the stomach or esophagus: this happens in about 1% of patients undergoing a specific type of antireflux surgery called Nissen fundoplication.
- Injuries to the spleen or liver: these can result in bleeding and happen in about 2.3% of patients. Severe injury, however, is rare.
- Dysphagia, or difficulty swallowing: this most commonly occurs due to swelling after surgery, but typically resolves on its own without needing further treatment.
Preventing Hiatal Hernia
Preventing hiatal hernias is often out of our control. However, it’s crucial for patients to stick to their prescribed medications and pay close attention to the instructions given after surgery. These instructions usually involve changing their diet in the period following the operation.
