Often referred to as the “great mimic” because symptoms can resemble many disorders, a hiatal hernia is created when the stomach slides through an upper diaphragm opening (called the hiatus) into the middle compartment of the chest creating discomfort, heartburn, chest pain, difficulty swallowing, regurgitation and anemia. The most typical risk factors are obesity, older age, major trauma to muscles around the n, scoliosis and being born with a large hiatus. There are two main types of hiatal hernia: the most typical being a “sliding hernia” where the top portion of the stomach moves up and out of the diaphragm’s hiatus and a “paraoesophageal hernia” which causes another area of the stomach or abdominal organ to move beside the esophagus.
Let’s take a closer look at these hernia types in more detail:
Type I: As mentioned above, this type is also known as a sliding hiatal hernia. There is a widening of the muscular hiatal tunnel and circumferential laxity of the phrenoesophageal ligament (which holds the stomach in place just below the diaphragm). This allows a portion of the gastric cardia (the point where the esophagus meets the stomach) to herniate upward into the posterior mediastinum (the area above the diaphragm). Oftentimes, Type I hernias are associated with gastroesophageal reflux disease. Since sliding hernias account for 95% of all hiatal hernias they are considered the most common.
Type II: This hernia type is also referred to as a paraesophageal hiatal hernia. The stomach herniates through the hiatus alongside the esophagus. Also known as a “pure” paraesophageal hernia, the gastroesophageal junction remains below the hiatus and the stomach moves in front of the esophagus outside he diaphragm and herniates into the chest. The condition is also called a giant paraesophageal hernia if it is more than 30 percent of the stomach herniating into the chest.
This type of hernia rarely occurs. However, paraesophageal hiatal hernias do account for most complications, but are less than five percent of all cases.
Type III: These hernias have the combined elements of both types I and II hernias. If there is increasing enlargement of the hernia through the hiatus, the phrenoesophageal ligament widens which leads to the displacement of the gastroesophageal junction above the diaphragm and thereby adding the sliding element common with a type II hernia.
Type IV: Type IV hiatal hernia is affiliated with a large defect in the phrenoesophageal ligament. This opening allows other organs such as the colon, spleen, pancreas and small intestine to enter the hernia sac.
The final stage of type I and type II hiatal hernias occurs when the entire stomach travels up into the chest by rotating 180° around its longitudinal axis with the cardia and pylorus as fixed points. This abnormality is usually called an intrathoracic stomach.
Endoscopy or medical imaging are typically used to confirm diagnosis. However, endoscopy is usually only required when disturbing symptoms are present, there is a strong resistance to treatment is or the person is 50 years of age or higher.
In most cases, hiatal hernia sufferers experience no life-changing discomfort and treatment is rarely required. If there is pain or discomfort, three or four sips of room temperature water will usually relieve the pain. Symptomatic patients should raise their head area of their beds and avoid lying down directly after meals. If the condition has been brought on by stress, techniques may be prescribed to help reduce it. If the patient is overweight, weight loss may be indicated and prescribed. Proton pumps such as antisecretory drugs inhibitors and H2 receptor blockers can be used to reduce acid secretion. Medications that reduce pressure on the lower esophageal sphincter (or LES) should be avoided.
However, in some unusual cases, the treatment of large sliding hiatal hernia and paraesophageal hernias requires surgery to correct the anatomy, reduce the hernia and repair the opening in the diaphragm (crural opening)., it may cause esophageal stricture or severe discomfort. About 5% of hiatal hernias are paraesophageal. If symptoms from this type of hernia are severe, for example, if chronic acid reflux threatens to severely injure the esophagus or is causing Barrett’s esophagus, surgery is sometimes recommended. However, surgery has its own risks including death and disability, so that even for large or paraesophageal hernias, watchful waiting may be safer and cause fewer problems than surgery. Complications from surgical procedures to correct a hiatal hernia may include gas bloat syndrome, dysphagia, dumping syndrome, excessive scarring, and rarely, achalasia. Surgical procedures sometimes are unsuccessful the first time around requiring yet another surgery to make repairs.
One surgical procedure used is called fundoplication. In fundoplication, the gastric fundus (upper part) of the stomach is wrapped around the inferior part of the esophagus which prevents herniation of the stomach through the hiatus and the reflux of gastric acid. The procedure is commonly performed laparoscopically. Recent studies have indicated laparoscopic fundoplication has shown relatively low complication rates, faster recovery and relatively good, long-term results.
As with most surgeries, there may be risks involved. If you think you need to be examined for a possible hernia, you deserve the most experienced Hernia Specialist. That is why you should visit the Digestive & Liver Disease Center of San Antonio. Call our team today at 210-941-1662 or book an appointment online!
