A hiatal hernia (HH, hiatal hernia, gastric hernia) is an enlargement of the esophageal opening of the diaphragm through which the esophagus normally penetrates into the abdominal cavity, and with a hernia, an abdominal organ, most often the stomach, penetrates into the chest. Sometimes intestinal loops and, extremely rarely, the spleen penetrate into the chest with hiatal hernia. This disease is quite common, it is found on average in 40% of the world's population. Fortunately, for the majority it does not cause any problems, but in 5 - 7% of all gastroenterological patients, complaints are caused by this particular disease (Figure 1).
Causes of hiatal hernia
Most often, it is not possible to find out the cause of the development of this disease in a particular patient. In general, hiatal hernia is a multifactorial disease and it can be difficult to identify one single cause unless there is a clear connection with trauma.
The following reasons for the development of a hiatal hernia are identified:
- Increased intra-abdominal pressure, for example due to overeating at night, or chronic constipation. Another reason for increased intra-abdominal pressure, and hence the development of hiatal hernia, is heavy physical labor.
- Congenital degenerative changes in the ligamentous apparatus and connective tissue.
- Age and associated connective tissue degeneration. Therefore, in these patients it is not uncommon to have a combination with an inguinal or ventral hernia.
- Blunt abdominal trauma.
- The presence of chronic diseases that disrupt the normal motility of the gastrointestinal tract (peptic ulcer, reflux esophagitis, cholelithiasis, diseases of the large intestine).
- Excess weight. In overweight people, intra-abdominal pressure increases, which leads to “squeezing” the stomach into the chest
Abdominal pain
Abdominal pain is a fairly common occurrence. It can be caused by many conditions - from mild gastritis to severe diseases.
I would like to dwell not on any specific disease, but on the general principles of approaching abdominal pain from the standpoint of surgery.
The primary goal of the surgeon is to determine whether the pain is caused by an acute surgical condition or whether the pain is a manifestation of a chronic or non-life-threatening condition.
Acute surgical diseases include conditions in which a person’s life is in immediate danger. Such diseases require emergency surgery or mandatory treatment and observation in a surgical hospital.
Acute surgical diseases include peritonitis (inflammation of the peritoneum), acute appendicitis, acute cholecystitis (inflammation of the gallbladder), acute pancreatitis (pancreatic necrosis) - inflammation of the pancreas), intestinal obstruction, perforated ulcer (as well as perforation of any hollow organ - intestine, etc. ), mesenteric thrombosis (blockage of intestinal arteries leading to intestinal necrosis), gastrointestinal bleeding, strangulated hernia and some others.
Classification of hiatal hernia
In our country, unfortunately, there are many classifications of this disease, but the most common classification proposed by B.V. Petrovsky and N.N. Kanshin. Following it, the following variants of the hiatal hernia are distinguished:
Axial:
- fixed
- unfixed
Without shortening of the esophagus
- cardiac
- cardiofundic
- subtotal
- total
With shortening of the esophagus
1st degree of cardia is fixed 4 cm above the diaphragm
Grade 2 cardia is fixed more than 4 cm in the chest
Paraesophageal
- fundamental
- antral
- intestinal
Now let's figure out what is what. So, a hiatal hernia is called axial if the esophagogastric junction is located above the diaphragm. It is called cardiac if only the cardia (upper part of the stomach) is located above the diaphragm, cardiofundal hernia is called if both the cardia and the fundus of the stomach go into the mediastinum, subtotal hernia is called if 2⁄3 of the stomach goes into the mediastinum (above the esophageal opening of the diaphragm), and, accordingly, total This is when the entire stomach is located in the chest.
A paraesophageal hernia is a situation when the esophageal-gastric junction (cardia of the stomach or simply cardia) is located in the abdominal cavity, and any part of the stomach or other organ penetrates through the esophageal opening of the diaphragm into the mediastinum (Figure 2).
What is an abdominal hernia?
Extension of the internal organs of the abdominal cavity and small pelvis through existing openings beyond their anatomical zone under the general outer covering or into another area is called an abdominal hernia. Unlike prolapse (loss) and eventration (depressurization), a hernial protrusion necessarily consists of three components:
- Gate (exit point).
- Sac (part of the peritoneum).
- Contents (internal organs and structures).
Most often, the hernial sac contains intestinal loops and the greater omentum.
Complaints with esophageal hernia
The most common complaint with hiatal hernia is heartburn.
. You can read more about heartburn here. Heartburn most often occurs at night or after eating while lying down; it often occurs after physical activity, especially in an inclined position. Sometimes heartburn is accompanied by chest pain. Most often, relief from this condition comes from taking antacids, such as reni, or drugs that reduce the production of hydrochloric acid in the stomach, such as omeprazole.
The next common symptom of this disease is pain
. It is of a burning nature, localized behind the sternum, and radiates to the right shoulder. The pain intensifies most often after eating or lying down. Sometimes it is accompanied by heart rhythm disturbances. Most often, the pain goes away after belching, or if the patient gets up and walks around. Sometimes pain in people with a hiatal hernia is confused with pain in the heart, especially since with hiatal hernia pain is often accompanied by arrhythmia. Pain is most often relieved by antispasmodics, no-spa, etc.
Another complaint among patients is belching
. Belching occurs with both food debris and air. Sometimes it is uncontrollable and occurs without reference to food intake. Often, this lack of control and unpredictability of the occurrence of the latter is the main reason for surgical treatment of patients with hiatal hernia.
Regurgitation
- throwing food into the oral cavity while lying down or bending over. This complaint is relatively uncommon and occurs more often with large hernias.
Dysphagia
- difficulty passing food through the esophagus, develops at the stage of complications of the hiatal hernia. Dysphagia is caused either by an inflammatory process in the walls of the esophagus, or by a cicatricial stricture (narrowing) of the esophagus. Dysphagia requires hospital treatment
Extraesophageal manifestations of hiatal hernia are also distinguished. The most common of this group of complaints is cough.
. Often a cough accompanies the patient for years. It occurs more often in a lying position or when bending over, after eating. The cough is accompanied by a constant sore throat.
The second most common extraesophageal complaint is arrhythmia
. Most often, arrhythmia occurs with a large hiatal hernia, when most of the stomach is in the chest. In this case, the arrhythmia is associated with eating or bending, or occurs in a lying position. Typically, when examining such patients, cardiologists do not find heart pathology. Another manifestation of hiatal hernia is chronic diseases of the ENT organs, pharyngitis and laryngitis. The connection between laryngitis or pharyngitis and the hiatal hernia can be confirmed or refuted using daily pH measurements of the esophagus.
In addition, the consequence of a hiatal hernia can be dental damage, hoarseness, bronchitis, and bronchial asthma.
Symptoms and signs
The clinical picture will depend on the location of the protrusion and existing complications. More often, the symptoms of an abdominal hernia will be as follows:
- the presence of education itself;
- pain of varying intensity and character, with possible irradiation and intensification with physical activity, coughing, sneezing, increased gas formation and constipation;
- disruption of the functioning of the organs that make up the contents of the hernial sac.
If complications occur, corresponding symptoms will appear. Sometimes, in addition to physical complaints, patients are concerned about aesthetic discomfort associated with the presence of an external defect. This can trigger emotional problems and depression.
Course of hiatal hernia
HH is a very common disease. As I already wrote, up to 40% of the world's population have this disease, but most of them do not even suspect it. Problems begin when the sphincter between the esophagus and stomach stops working and the contents of the latter enter the esophagus. Or if the hernia of the PAD reaches a large size and causes complications associated with neighboring organs (arrhythmias, pneumonia, etc.). In most cases, with proper treatment, the course of the disease is favorable, and conservative therapy is sufficient. Therapy is aimed at reducing the reflux of gastric contents into the esophagus, relieving inflammation, and normalizing gastrointestinal motility. If conservative therapy is not effective, surgical intervention must be resorted to.
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More details
Hernias of the anterior abdominal wall are one of the most common human diseases; they are observed in 2-4% of the total population of the planet. A hernial protrusion is the exit of the peritoneum in the form of a bag with the insides contained in it through any defect of the abdominal wall beyond its limits. There are inguinal and femoral hernias, hernias of the white line of the abdomen and Spigelian line, postoperative ventral hernias, etc.
Complications of hiatal hernia
Erosion and ulcers of the esophagus occur in 7 - 9% of cases in patients with hiatal hernia. This complication is associated with the aggressive action of gastric juice, which enters the esophageal mucosa. Usually the presence of ulcers and erosions is accompanied by the most severe complaints of patients. The danger of an ulcer is that if not treated correctly, a scar may form at the site of the ulcer, which in turn can lead to obstruction of the esophagus. In the presence of multiple erosions, chronic anemia may develop. The presence of an ulcer in the esophagus is an indication for surgery.
Bleeding and anemia with hiatal hernia occur in 11 - 20% of cases. Bleeding most often occurs due to vomiting, for example after poisoning. Such bleeding can be quite massive and require emergency hospitalization. Bleeding can be manifested by vomiting blood, or so-called coffee grounds, dark coffee-colored contents. Sometimes bleeding may appear as black, tarry stool. In case of repeated episodes of bleeding, surgical treatment is indicated.
Anemia occurs in two cases. The first is chronic minor blood loss against the background of the presence of multiple erosions of the esophageal mucosa. This bleeding occurs periodically and goes unnoticed, and can continue for months. The second reason is a violation of iron absorption against the background of inflammatory changes in the stomach. This anemia is called iron deficiency and develops when most of the stomach is in the chest. Anemia manifests itself as severe weakness.
Cicatricial stricture of the esophagus. With a long-term inflammatory process in the wall of the esophagus against the background of the hiatal hernia, scars are formed that narrow the lumen of the esophagus. A stricture appears, a disruption in the passage of food through the esophagus. This complication is manifested not by the ability to eat, first with solid food, but as the process progresses, with liquid
Incarcerated hiatal hernia. A very rare complication, but extremely dangerous, which in the absence of qualified medical care leads to death. This complication is manifested by the sudden appearance of severe bursting pain in the chest, a feeling of fullness. Patients constantly try to induce belching, which is either impossible or does not bring relief. This complication requires emergency surgery.
To summarize, I would like to repeat that with proper treatment, complications of the hiatal hernia develop quite rarely.
Hernias “amenable” and hernias “intractable”
All inguinal hernias can be operated on using laparoscopic techniques. These include direct, oblique inguinal and femoral hernias.
Laparoscopic hernioplasty is especially indicated:
- For large inguinal-scrotal hernias;
- For recurrent inguinal hernias;
- Bilateral inguinal hernias;
- When an inguinal hernia is combined with other surgical diseases, if a simultaneous operation is planned.
In the first two cases, traditional operations are accompanied by a large number of relapses. In the other two, open operations are usually performed in stages.
We consider the presence of severe concomitant cardiovascular diseases in the patient as relative contraindications to laparoscopic hernioplasty. These operations are also not indicated during late pregnancy.
Diagnosis of hiatal hernia
The main role in diagnosis is played by X-ray examination with barium and gastroscopy.
X-rays are performed on an empty stomach using a barium contrast solution. The doctor monitors the passage of contrast through the esophagus and stomach on the X-ray machine screen. Thanks to X-ray examination, it is possible to identify the size of the hernia, the presence or absence of reflux of gastric contents into the esophagus, the presence or absence of disturbances in the passage of contrast through the esophagus and stomach.
Gastroscopy allows you to assess the condition of the esophageal mucosa, the presence or absence of inflammation, erosions, ulcers, and the presence of narrowing. In the vast majority of cases, these two studies are sufficient to make the correct diagnosis. In some cases, a CT scan is performed to evaluate the presence or absence of a hiatal hernia and its size. If there are non-esophageal manifestations or an unclear clinical picture, daily pH measurements are performed. A thin probe is installed into the lumen of the esophagus for 24 hours, which records the reflux of gastric contents into the esophagus, making it possible to identify the connection between complaints and reflux of gastric contents.
Etiology and pathogenesis
Pulmonary hernias can occur spontaneously or due to external influences. Spontaneous pulmonary hernias, as a rule, appear due to excessive protrusion of the apex of the lung through the superior opening of the chest. Acquired lung hernias develop at the site of defects in the chest wall after surgery on the chest (thoracotomy), closed chest injury with complete rupture of the intercostal muscles in a limited area without damage to the skin (observed with a small area of application of traumatic force) or penetrating wounds of the chest.
Treatment of hiatal hernia
In the vast majority of cases, conservative therapy is carried out, which in fact is symptomatic and is aimed at improving the well-being of patients and preventing the development of complications. The main cause of complaints from patients is the reflux of aggressive gastric contents into the esophagus. Therefore, proton pump inhibitors (esomeprazole, Nexium, etc.) are prescribed. This is a group of drugs that reduce the acidity of gastric juice, thereby minimizing the damaging effect on the esophageal mucosa. Enveloping drugs in the form of suspensions are also used, such as Gaviscon, Maolox, Almagel. These drugs effectively reduce the acidity of gastric juice and, by enveloping the walls of the esophagus, protect them from reflux. And the third group of drugs are prokinetics (Motilium, Ganaton). These are medications that improve and normalize the motility of the esophagus and stomach, thereby reducing the frequency of reflux.
This therapy leads to improved well-being and quality of life. Unfortunately, up to 80% of patients experience a relapse of complaints immediately after stopping taking the drugs and therefore have to take them constantly. Complete removal of a hiatal hernia is only possible through surgery. You can read about surgical treatment of hiatal hernia here
Author: Ph.D. Siyukhov R.Sh.
When choosing treatment, choose a surgeon!
It can be said that in the Department of Surgery of the Center for Endosurgery and Lithotripsy, almost all modern methods of treating hernias of the anterior abdominal wall of any location and anatomical structure are widely used. In addition, I would like to note that the team of surgeons has been working in the same composition for more than 10 years, which undoubtedly affects the coherence of the work and the quality of the operations performed.
Patients who have undergone hernioplasty in our department are carefully monitored by our specialists for several years, being, so to speak, under “guaranteed service.” This approach allows us to constantly improve and improve the quality of surgical treatment.
Is it possible to cure an intercostal hernia using traditional methods?
Traditional medicine recipes for pulmonary hernia can only be used to suppress the cough reflex, since the main method of treating such pathologies is surgical correction. Below are methods and recipes for combating chronic cough (including in smokers), which will help reduce the risk of exacerbations and reduce the manifestations of pain in people with a diagnosed lung hernia.
Inhalations with saline solution
Such inhalations have a positive effect on the functional state of the respiratory tract, moisturize the mucous membranes and cleanse them of accumulated dust and toxic substances. Inhalations should be done for preventive purposes 1-2 times a day in short courses - for 7-10 days in a row. The duration of the procedure is no more than 10 minutes. The amount of solution per procedure for an adult is 3-4 ml.
Inhalations with saline solution moisturize the mucous membranes and cleanse them of accumulated dust and toxic substances
Inhalations are contraindicated at high temperatures or active bleeding.
Need to know! Saline solution is a physiological sodium chloride solution with a salt concentration of 0.9%.
Herbal teas
For chronic cough, it is useful to drink 3-4 cups of decoction or tea of chamomile, St. John's wort, thyme or oregano daily. These herbs have anti-inflammatory and antiseptic effects, improve mucus discharge and soothe irritated throat mucous membranes in people with tobacco addiction. A strong infusion can also be used as a gargle.
Herbal teas improve mucus discharge and soothe irritated throat mucous membranes
Warm milk drinks
Warm milk is an excellent remedy for combating dry and wet coughs, which can be used with almost no restrictions (with the exception of persons with congenital intolerance to milk sugar, as well as patients with infectious lesions of the stomach and intestines). You can add a little mint, a spoonful of natural honey or two spoons of banana puree to warm milk. You should drink this drink 2-3 times a day in between meals for 5-7 days in a row.
Warm milk is an excellent remedy for dry and wet coughs.
Reasons for formation
The main reasons for the formation of intervertebral hernia are:
- increased load on the disk;
- disk power failure;
- disc asymmetry due to incorrect position of the overlying and underlying vertebrae.
Most often, a hernia is formed due to osteochondrosis, a disease characterized by degenerative-dystrophic changes in the spine. As a result of this process, the core tissue extends into the area of the annulus fibrosus. The disc ceases to fully perform its functions, and the vertebra, which is located above, shifts in relation to the lower one. The result of dystrophic changes is the formation of a hernia with disruption of the integrity of the fibrous ring and compression of the nerves by the nucleus pulposus, and in severe cases, the spinal cord.
Factors that may contribute to the formation of a herniated disc include:
- lifting weights;
- constant exposure to vibration;
- improperly distributed load on the spinal column during curvature;
- obesity;
- previous spinal injuries.
The risk of developing intervertebral hernias is higher in people who lead a sedentary lifestyle. Those who subject their bodies to increased physical stress, such as professional athletes, are also at risk.
Clinical picture
Pathophysiological manifestations in most cases are mild or absent altogether. Pain, which is the dominant symptom of most of these pathologies, is practically absent with a hernia of the lung or diaphragm. The patient may complain of moderate pain at the location of the defect, while the pain syndrome almost always has a clear localization (a person can show exactly where it hurts). With an intercostal hernia, there is a clear connection between pain and coughing, physical activity (running, climbing stairs), and straining. In severe cases, when the formation reaches a large size, pain may increase when turning over during sleep, as well as changing body position in a static state.
Possible locations of pain in intercostal hernia
The nature of pain during a lung hernia is pulling, aching. Less commonly, patients report burning or cutting sensations. Visually, the defect may not be detected for a long time, especially if the pulmonary sac is small. As the hernia grows, the pain becomes more intense and other clinical signs become more pronounced. A typical clinical presentation for an intercostal hernia consists of the following symptoms:
- swelling and swelling of the skin at the location of the defect;
- bulging under the skin mainly in the projection of the intercostal spaces;
- an increase in the size of the protrusion and the intensity of existing symptoms after coughing or exertion, leading to excessive contraction of the pectoral muscles.
If the hernia reaches an impressive size, it can compress the nerve endings extending from the spinal cord, causing neuralgic disorders - thoracalgia (intercostal neuralgia). Pain in the complicated course of a pulmonary hernia occurs not only at the location of the protrusion, but can also radiate to the heart, scapula, collarbone and along the entire chest. The pain syndrome is of high intensity, does not go away at rest or during night sleep, has a burning character and does not allow normal breathing (shortness of breath becomes constant).