A hiatal hernia is the protrusion of some portion of the stomach into the thoracic cavity through the opening in the diaphragm through which the esophagus passes (the esophageal hiatus). The two major varieties of hiatal hernia are (1) sliding hernias (most common), in which the gastroesophageal junction and the upper portion of the stomach slide upward through the esophageal hiatus; and (2) paraesophageal, or “rolling,” hernias, in which the gastroesophageal junction remains fixed, but some portion of the stomach passes through the esophageal hiatus. Occasionally, a hiatal hernia exhibits characteristics of both the sliding and rolling hernia.
FIGURE. Types of hiatal hernias.
The cause of hiatal hernias is unclear. They may be due to intra-abdominal pressure or weakening of the gastroesophageal junction caused by loss of muscle tone or trauma. Risk factors include severe coughing or vomiting, lifting heavy objects, pregnancy, and straining at stool. The incidence of hiatal hernia increases with age. Prevalence is higher in women than in men, and obesity is a contributing factor.
Signs and Symptoms
Over half of hiatal hernias may remain asymptomatic. If symptoms are present, they commonly include heartburn—aggravated by reclining, belching, esophageal reflux or GERD, dysphagia, or severe pain if a large portion of the stomach is caught above the diaphragm.
Diagnosis of hiatal hernias is made by chest x-ray, barium x-ray, endoscopy and biopsy, and pH studies of any reflux (to eliminate the possibility of gastric ulcer).
The goal in treatment is to alleviate symptoms. Surgery is not the first choice of treatment unless strangulation of the hernia is evident or symptoms cannot be controlled. An attempt is made to reduce heartburn and reflux or GERD through dietary modification or by strengthening the LES with medication. Antacids, H2 blockers, and PPIs likely are prescribed. Activity restrictions may be indicated to reduce intra-abdominal pressure, and persons may be advised to avoid tight or restrictive clothing. Stool softeners and laxatives to prevent straining at stool may be prescribed. Avoidance of food intake before sleep and elevation of the head of the bed may be suggested.
Diet modifications include avoidance of spicy or fried foods, caffeine, carbonated drinks, citrus juices, alcohol, peppermint, and green and red peppers and strictly avoiding overeating. Deep breathing exercises to strengthen the diaphragm and expand the lungs may be helpful.
Explain diagnostic tests, treatment, and significant symptoms to clients. Describe dietary restrictions and warn against activities that increase intra-abdominal pressure.
The prognosis for a hiatal hernia is good with proper treatment. Complications including stricture, significant bleeding, pulmonary aspiration, or strangulation require surgical repair. Strangulation is a medical emergency. It occurs when the hernia contents become swollen and compromise blood supply to the bowel. This causes significant abdominal pain and vomiting.
There is no known prevention of hiatal hernias.