Hiatal hernia: symptoms, causes and treatment
Hiatal hernia is a protrusion of the stomach through a hole in the diaphragm, called the oesophageal hiatus. Through the latter, a portion of the stomach passes into the chest
This condition is quite common and may not cause any discomfort.
In such cases, surgery or drug treatment is not necessary.
Most hernias develop asymptomatically, but an increased incidence of acid reflux can generate the symptoms of gastro-oesophageal reflux syndrome (i.e. the rising of gastroduodenal secretion into the oesophagus).
In reality, it is quite common for hiatal hernia and gastro-oesophageal reflux to occur simultaneously
However, there is no evidence to suggest that one is the cause of the other.
As mentioned, a hiatal hernia is identified with a rising part of the stomach from the abdomen into the chest, through an opening in the diaphragm.
Normally, its walls are well adhered to the oesophagus.
With advancing age, however, these structures may lose tone and thus facilitate the passage of a small portion of the stomach into the thorax.
This phenomenon has no certain origin and may be linked to congenital factors or diet. In Italy, after the age of 60, this disorder affects one in 10 people.
Very often, hiatal hernia is asymptomatic and can only be diagnosed following tests such as X-rays and gastroscopy, perhaps performed for other purposes.
The most common symptoms are digestive complaints (dyspepsia) such as abdominal bloating, feeling full, belching, nausea or vomiting.
General symptoms
The rise above the diaphragm of a more or less large portion of the stomach generates the anatomical loss of an angle, known as the angle of His, thus facilitating the onset of reflux and associated symptoms.
The latter can be classified into
- typical symptoms, such as retrosternal burning or heartburn and regurgitation of acidic material
- atypical symptoms, such as coughing, asthma, chest pain (similar to cardiac pain), recurrent bronchitis, hoarseness and a feeling of a lump in the throat (or hysterical bolus).
Types of hiatal hernia and other symptoms
Hiatal hernia anatomically is classified as:
- gliding hiatal hernia, with the gastroesophageal sphincter and proximal portion of the stomach rising above the diaphragm
- paraesophageal hernia, where the sphincter remains in place and only a portion of the fundus ascends towards the chest
- mixed hernia where, in addition to the fundus, the cardia (i.e. the orifice connecting the oesophagus to the stomach) also ascends. These are the ones that usually become larger and require different treatment.
Typical symptoms of hiatal hernia slippage include:
- heartburn (heartburn), especially after meals
- acid reflux in the mouth or airways
- retrosternal pain
Symptoms may become more pronounced with the intake of foods that promote abdominal distension or, in general, when conditions that generate increased abdominal pressure occur, with the presence of
- frequent belching or a sense of bloating
- nausea
- difficulty swallowing
- halitosis
- intense salivation
- hoarseness
Hiatal paraesophageal hernia: what to know
A hiatal paraesophageal hernia occurs when the bottom of the stomach is pushed over the diaphragm next to the oesophagus, despite the connection point between the oesophagus and the stomach being in normal position below the diaphragm.
Most paraesophageal hernias are a consequence of a slipped hernia and are age-related.
Typically, they are asymptomatic, but when the hernia becomes trapped or compressed by the diaphragm, decreasing the blood supply (a condition referred to as ‘strangulation’), it becomes painful and necessitates urgent surgical intervention.
Mixed hiatal hernia: what to know
Mixed hernia, which is rarer, is characterised by the simultaneous presence of the two types of hernias described, i.e. a sliding hernia and a paraesophageal hernia.
The symptoms are similar to those of the previous two forms, with a cumulative effect that inevitably makes them more severe.
Hiatal hernias can appear small (2 or 3 centimetres) or, on the contrary, they can take on larger volumes, affecting a large part of the stomach.
In addition to the typical symptoms, the person suffering from a hiatal hernia may experience other complaints such as
- dysphagia
- anaemia
- tachycardia or arrhythmia
Other disorders related to hiatal hernia
Dysphagia, i.e. difficult swallowing, can occur when the portion of the gastric fundus that is herniated and caged in the chest registers an abrupt constriction at the diaphragmatic level, which can hinder the progression of ingested food and causes an overdistension of the herniated part of the stomach.
The dilatation of the ‘gastric pouch’ can cause retrosternal feeling of weight and lead to episodes of vomiting.
As the volume of the hernia increases, the condition of gastric volvulus (i.e. rotation of the stomach on its own axis) can occur, which can increase vomiting episodes and also generate a form of gastric ischaemia, especially at the mucosal level with possible digestive haemorrhage.
Anaemia is a process that can take shape over time.
The stomach mucosa suffers from being located in a negative pressure cavity such as the thoracic cavity.
Microhaemorrhagic gastritis or small ulcerative lesions of the mucosa with a tendency to bleed may appear.
These are not acute haemorrhages, but rather small chronic losses that over time can bring the patient’s haemoglobin to very low levels compared to the standard, leading to the onset of symptoms such as fatigue and weakening.
Tachycardia is related to the condition whereby the herniated stomach, dilating in the postprandial phase, rests on the pericardium, irritating it and leading to tachycardia and sometimes arrhythmias.
Hiatal hernia: possible causes
To date, the causes of hiatal hernia are not known with certainty.
Undoubtedly, there is a weakening or stretching of the bands of tissue anchored between the oesophagus and the diaphragm at the hiatus.
This would cause the diaphragmatic hiatus to widen and the stomach to pass into the chest.
It appears that this condition may be related to a strong genetic component and that its onset is encouraged by common causes such as age, smoking and being heavily overweight.
Ultimately, hiatal hernia can be linked to:
- congenital defect, whereby the hiatus is wider than normal
- abdominal trauma
- diaphragm modification related to advancing age
- excessive increase in intra-abdominal pressure due to contraction of the abdominal muscles (e.g. due to straining during evacuation, lifting a weight, coughing or vomiting)
- increased abdominal pressure in pregnancy
How to treat it
If it is not associated with reflux, hiatal hernia does not require specific treatment.
Of course, it is always desirable to follow a healthy lifestyle and a careful diet that includes the elimination of acidic, spicy, fatty or spicy foods, as well as the limited consumption of coffee, alcohol and acidic drinks such as fruit juices or cola.
If, on the other hand, hernia occurs together with reflux syndrome, treatment is directed against the latter, i.e. with proton pump inhibitors or H2 antagonists.
At the same time, some useful measures can be used to reduce reflux, especially during the night hours, such as
- raising the head of the bed
- the habit of eating dinner early and waiting at least three hours before going to bed
- avoiding fluid-rich meals and drinking heavily after dinner.
By easing the symptoms of reflux disease, those associated with hiatal hernia should also gradually fade.
The surgical solution is reserved only for the most severe cases, in which the passage of at least two thirds of the stomach into the chest causes functional damage that can only be resolved in the operating theatre.
For hernias up to two centimetres, without reflux, monitoring over time is almost always opted for.
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