What is Sliding Hernia?
There are different types of hiatal hernias, which is a condition where part of the stomach pushes into the chest cavity through a “hiatus” or a hole in the diaphragm. But, the most common type that accounts for up to 95 percent of all cases is a sliding hiatal hernia, also known as type 1. In sliding hiatal hernia, the junction between the stomach and the esophagus (digestive area where food passes) slides upward into the chest cavity.
The other three types of hiatal hernias, known as type 2, 3, and 4, are considered paraesophageal hernias. Unlike type 1, they involve parts of the stomach or other organs alongside the junction of the stomach and esophagus, bulging into the chest cavity.
In a type 2 hiatal hernia, part of the stomach, most often the upper part known as the ‘fundus’, pushes into the chest cavity, while the junction between the stomach and esophagus remains in its normal position. In a type 3 hernia, part of the stomach protrudes into the chest cavity and the junction between the stomach and esophagus is also displaced upward. The type 4 hernia is similar to type 1 and type 3, but another organ, usually part of the large intestine, also pushes into the chest cavity.
What Causes Sliding Hernia?
In a sliding hiatal hernia, a part of the stomach called the gastroesophageal (GE) junction moves up above the diaphragm, the muscle that separates the chest from the abdomen. This is due to the loosening of a band of tissue connecting the diaphragm and the esophagus called the phrenoesophageal ligament. Even though the ligament doesn’t break, the GE junction relocates into an area behind the heart and lungs known as the posterior mediastinum. Because there’s less esophagus in the abdomen, the junction malfunctions, which can lead to acid reflux.
It’s harder to explain types 2 to 4 hernias because they don’t have a single main cause. Most paraesophageal hernias (PEHs), another name for these hernias, have multiple causes. They are often connected to widening of the gap in the diaphragm through which the esophagus passes or can be congenital (present from birth) or acquired from a previous surgical procedure, an injury, constant high abdominal pressure or shortening of the esophagus due to fibrosis (the thickening and scarring of connective tissue) or scarring caused by repeated exposure to harmful substances.
Risk Factors and Frequency for Sliding Hernia
Sliding hiatal hernias are quite common, affecting between 10% to 60% of people. The majority of these, about 95%, are sliding hiatal hernias, and the rest are paraesophageal hernias. People over 50, obese individuals, and those with conditions that increase pressure in the abdomen, like chronic constipation or excessive vomiting, are most likely to develop these hernias. Among paraesophageal hernias, type 3 is the most common, while type 2 is the least common. When they refer to a “giant hiatal hernia,” they’re talking about a hernia where 30% or more of the stomach is located above the hiatus and in the chest cavity.
- Sliding hiatal hernias impact 10% to 60% of individuals and make up 95% of all hiatal hernias.
- The rest of hiatal hernias are paraesophageal, with type 3 being more common than type 2.
- Older people, especially those over 50, are more likely to have these hernias.
- Obese people and those with conditions like chronic constipation or excessive vomiting, which increase abdominal pressure, are also more at risk.
- A “giant hiatal hernia” is one where over 30% of the stomach is located above the hiatus in the chest.
Signs and Symptoms of Sliding Hernia
Sliding hernias or type 1 hernias often don’t have any symptoms. But when symptoms do show up, they are generally vague. Common symptoms can include discomfort or a feeling of fullness in the upper abdomen, and a history of GERD (Gastroesophageal Reflux Disease). This occurs due to the length of the esophagus within the abdomen being too short, leading to stomach contents flowing back into the esophagus.
People with PEHs (Paraesophageal Hernias) can develop symptoms related to blockages. If the blockage happens where the stomach and esophagus meet, the most common symptom is difficulty swallowing. If anything is left in the lower part of the esophagus, it will return back up, a process called regurgitation. However, if the lower part of the stomach gets blocked, it can cause the upper part of the stomach to expand. This can lead to feeling nauseous or vomiting and sometimes chest pain that extends to the back.
When patients develop Cameron ulcers, they may show signs and symptoms of anemia. These can include pale skin and feeling tired, especially when there’s a gradual loss of blood that’s not visible to the naked eye.
Testing for Sliding Hernia
To diagnose a hiatal hernia, your doctor will generally use three main methods: radiographic imaging, upper endoscopy, and esophageal manometry. Hiatal hernia refers to when a part of your stomach pushes up through your diaphragm, causing discomfort and other issues. Understanding how these diagnostic methods work can help you better understand your condition and treatment.
A radiographic imaging method, often referred to as an upper gastrointestinal (GI) series, is typically first in diagnosing hiatal hernias. This series of X-ray images allows your doctor to see where the junction between your stomach and esophagus is located, the size of the hernia, and the orientation of your stomach.
The second method that doctors often use is called an upper endoscopy. This process involves inserting a thin, flexible tube with a camera down your throat to see the stomach and esophagus. Doing this allows your doctor to check directly on the amount of stomach that has moved into the chest and if any ulcers have formed in the area.
The third method is high-resolution manometry (HRM) and esophageal pressure topography (EPT). This method helps detect hiatal hernias by looking at a pressure gap between the opening in the diaphragm through which the esophagus passes (the crural hiatus) and the junction between the esophagus and stomach (the GE junction). This diagnostic technique provides your doctor with important information regarding the pressure within the digestive tract, the function of the lower esophageal sphincter (the muscle that controls the passage between the esophagus and stomach), and the coordinated contractions of the esophagus. This information is particularly crucial when planning surgery as it could help determine which procedure will be used if a hiatal hernia repair is needed.
Treatment Options for Sliding Hernia
People with a type 1, or sliding, hernia typically don’t need surgery. Instead, the main treatment focuses on managing acid reflux, which could be caused by the hernia. This is usually done with medications known as proton-pump inhibitors and H-2 blockers, which work to reduce the amount of acid your stomach produces.
The decision to perform surgery on patients with paraesophageal hernias, another type of hernia, who have no symptoms, is a bit controversial. Most experts don’t recommend it because each year, only about 2% of such patients develop symptoms where emergency surgery is necessary. On the other hand, the death rate for elective (non-emergency) repairing surgery is around 1.5%. Even so, virtually all experts agree that surgery provides benefits for patients who do have symptoms.
The go-to surgical treatment is laparoscopic repair. This is a minimally invasive operation that involves making small incisions (cuts) in the abdomen. There are four main parts to this procedure: removing the hernia sac, ensuring that the esophagus (the tube that connects your mouth and stomach) inside the abdomen is long enough, repairing the hiatal defect (basically, fixing the hole in the diaphragm through which the hernia had passed), and attaching the stomach to the wall of the abdomen to prevent reflux (or backward flow of stomach contents) as a consequence of the procedure.
What else can Sliding Hernia be?
These are some conditions that could affect the esophagus and the stomach:
- Achalasia (a rare disorder that makes it hard for food and liquid to pass into your stomach)
- Esophageal Cancer (cancer of the esophagus)
- Esophageal Diverticulum (pockets in the esophagus that can trap food)
- Esophageal Dysmotility (difficulty in swallowing due to esophagus muscles not working properly)
- Esophagitis (inflamed or irritated esophagus)
- Gastric Outlet Obstruction (blockage of the path out of the stomach)
- Gastroparesis (delayed stomach emptying)
- GERD (Gastroesophageal reflux disease, a type of long-lasting acid reflux)
- Paraesophageal Hernia (when the stomach bulges through a weak spot in the diaphragm)
