Axial hiatal hernia (cardinal, sliding)

Axial hiatal hernia is one of the types of hernia formations. The pathology is widespread among the population and follows in frequency behind gastric ulcers and cholecystitis. Most often found in older people, only 19% occur in young people.

The name is associated with the displacement of the contents of the hernial sac along the axis of the esophagus (axially). Treatment in the initial stages allows you to permanently get rid of unpleasant symptoms and prevent complications. It is important that with a hernial protrusion of grade 1–2, there are practically no signs of the disease and the disease is detected during a routine examination or when visiting a doctor for another reason.

A little about the anatomical structures involved

The human diaphragm is located approximately at the level of the lower edge of the ribs. This is a strong unpaired muscle consisting of striated fibers. It separates the thoracic and abdominal cavities. Directed with two domes upward. For the passage of the most important vessels, nerve plexuses and digestive tube, it forms 3 main openings. The food transport channel is located at level 10 of the spine. The tract is formed by muscle bundles called “medial crura”. It simultaneously contains the anterior vagus nerves.

The diaphragmatic muscles assist the digestive organs in moving food (the muscle ring in the opening serves as a sphincter). In addition they:

support gastric motility;
contracting simultaneously with the abdominal muscles, they reduce intra-abdominal pressure.

The functions of the diaphragm depend on its tone. In the stomach directly adjacent to the diaphragm, the following sections are distinguished:

cardiac - the uppermost, in the zone of transition of the esophagus;
pylorus (antrum) – is the exit to the duodenum;
bottom – dome over the cardiac region;
body - the area between the cardiac and pyloric regions.

All parts of the stomach are located in the abdominal cavity.

A hernia is formed by an abnormal relationship between the stomach and the diaphragm, when the enlarged passage contains underlying sections that can penetrate into the chest cavity

Mechanism of hernia formation

According to the mechanism of development of a hernia, including axial, there can be:

congenital - fetal anomalies, underdevelopment of the medial muscular legs of the diaphragm with impaired formation of the closing ring, are detected in childhood;
acquired.

The study of the mechanism of acquired hernias showed significance in old age:

atrophic changes in the muscle ring;
prolapse of the diaphragm, causing expansion of the esophageal opening;
relaxation of surrounding fascia.

In middle and young age, the following are more important:

increased intra-abdominal pressure;
a decrease in the strength of the esophageal-phrenic membrane, which fixes the position of the cardia of the stomach and esophagus, its rupture and thinning leads to the penetration of the cardia into the chest cavity.

An anatomical and physiological feature of sliding hernias is a violation of the obstacle to regurgitation (reverse movement of food). The esophagogastric junction below the diaphragm appears as an acute angle (called the angle of His). The apex of the angle forms a fold of the mucous membrane, which acts as a valve. Together with the muscle sphincter of the cardiac region, it creates a mechanical obstacle to the regurgitation process.

The development of an axial hernia causes a flattening of the angle, which leads to the disappearance of the valve. Therefore, gastroesophageal reflux occurs (return of contents from the stomach).

Postoperative period

In cases of uncomplicated course of the disease and successful laparoscopic surgery, postoperative management of patients does not go beyond standard measures (pain relief according to indications, antibiotic prophylaxis during surgery and on the 1st day after it, nutrition with liquid food from the 1st day, removal of safety drainage through 12-24 hours). The duration of hospitalization is on average from 2 to 5 days.

If complications develop, appropriate therapy is provided. To evaluate the results of treatment, it is recommended after 3-6 months. perform gastric X-ray, endoscopy and pH monitoring.

Types of hernias

There are many classifications of hiatal hernias. The most common practice is to distinguish three types:

sliding (axial) - characterized by the obligatory movement of the lower part of the esophagus of the adjacent stomach from the abdominal cavity to the chest cavity and back;
paraesophageal (paraesophageal) - only the upper parts of the stomach pass through the diaphragmatic opening;
combined - have characteristics of both types.

Paraesophageal hernias often cause strangulation

Sliding hernias differ in their ability to self-reduce in an upright position:

for fixed ones - they do not move on their own;
non-fixed - when lifted from a horizontal to a vertical position, all falling parts return to their place.

Among sliding hernias, based on the abnormal mobility of individual parts of the esophagus and stomach, they are distinguished:

esophageal - only the lower part of the esophagus passes into the opening;
cardiac – the cardiac part of the stomach falls out;
axial-cardiac - after the esophagus, part of the cardia enters the opening;
cardio-fundal - part of the fornix and cardiac part of the stomach are found in the thoracic cavity.

According to the classification proposed by B.V. Petrovsky and N.N. Kanshin, the following are added to the group depending on the volume of the displaced stomach:

subtotal - a small part of the organ enters the hernial sac;
total hernia - the entire stomach comes out into the hernial opening.

At the same time, shortening of the esophagus is observed. Axial hernia accounts for up to 90% of all cases. More often observed in older women. According to the mechanism of occurrence, sliding hernias are distinguished:

Causes of the disease

A hernia can be diagnosed at birth and be congenital. The pathology develops as a result of underdevelopment (shortening) of the esophagus and requires timely surgical correction. Congenital hiatal hernia is a rare pathology.

An acquired hernia develops due to a weakening of the ligamentous apparatus, as a result of which the esophageal opening of the diaphragm expands. This occurs for various reasons:

In persons with connective tissue weakness, suffering from related diseases (for example, varicose veins and others).
As a result of increased intra-abdominal pressure, which is facilitated by pregnancy, a high degree of obesity, ascites, trauma, heavy lifting, persistent cough in chronic pathology of the bronchopulmonary system, etc.
Increased motility of the gastrointestinal tract.
Shortening of the esophagus due to its deformation resulting from burns or various inflammatory diseases.
Asthenia of the patient against the background of sudden weight loss.

How is the degree of hernial protrusion determined?

The degree of protrusion of the hernial sac depends on the transition of the adjacent parts into the chest and is detected by x-ray:

first - only the final part of the esophagus is located above the diaphragm, which is normally located inside the ring, the size of the hole does not allow the stomach to be wedged in, often accompanies peptic ulcers, appears against the background of gastroduodenitis, intestinal diverticula;
second - the abdominal part of the esophagus and the upper part of the cardia of the stomach pass into the chest cavity;
third, the hernial sac contains both the abdominal part of the esophagus and the entire stomach with its contents.

The progression of the disease is associated with continued exposure to causative factors. Timely elimination allows you to manage with diet and conservative methods of therapy.

Our services

The administration of CELT JSC regularly updates the price list posted on the clinic’s website. However, in order to avoid possible misunderstandings, we ask you to clarify the cost of services by phone: +7

Service name	Price in rubles
Appointment with a gastroenterologist (primary)	4 200
Fluoroscopy and radiography of the esophagus	2 600
Gastroscopy (videoesophagogastroduodenoscopy)	6 000

All services

Make an appointment through the application or by calling +7 +7 We work every day:

Monday—Friday: 8.00—20.00
Saturday: 8.00–18.00
Sunday is a day off

The nearest metro and MCC stations to the clinic:

Highway of Enthusiasts or Perovo
Partisan
Enthusiast Highway

Driving directions

Symptoms

Changing the position of organs leads to reflex disorders of the digestive process. The most characteristic symptoms are:

Pain syndrome is mainly localized along the midline in the area of the angle connecting the ribs (epigastric region), retrosternally. The intensity of the pain varies, often radiating to the shoulder and back. Similar to a cardiac attack.
Heartburn – accompanied by pain, begins after eating or during movement (contributes to gastroesophageal reflux). Patients note increased pain when lying down. The condition improves after taking milk, soda solution, and walking.
Swallowing impairment (dysphagia) is variable, there is difficulty in swallowing dry food (“a lump gets stuck”), pain when passing food through the esophagus, belching. Often associated with concomitant esophagitis. May last for several years.

Pain is triggered by eating and physical activity

Less common:

salivation;
nausea and vomiting;
prolonged hiccups;
feeling of bitterness in the mouth;
hoarseness of voice.

Recovery after surgery

After the operation is completed, the patient is transferred to the inpatient department, where doctors monitor his condition. If the patient feels well, he or she may be discharged the next morning. The rehabilitation period after removal of a gastric hernia is 3-4 weeks. The patient’s main task at this time is to follow the doctor’s recommendations for a quick recovery and return to their normal lifestyle. In order for the body to quickly recover after surgery, you need to follow the following rules:

Stick to bed rest.
Do not lift heavy objects, put off physical activity for a while.
Go on a diet - your diet should include low-fat, fresh food in pureed or liquid form.
Take medications - analgesics, proton pump blockers.

If symptoms such as bleeding, pain, or suppuration of wounds appear, you should immediately consult a doctor. After laparoscopic repair with fundoplication, recurrence of the disease is unlikely.

Complications

The most common complication and manifestation of sliding hiatal hernias is reflux esophagitis, which is caused by upward reflux of gastric contents. In addition, the patient may develop:

peptic ulcer of the esophagus;
cicatricial changes (strictures) with narrowing of the esophagus;
bleeding from the veins of the hernial part;
shortening of the esophagus;
Barrett's esophagus (replacement of the multilayered epithelial covering of flat forms of esophageal epithelium with single-layer cylindrical cells from the stomach or intestines), a precancerous disease.

Nutrition rules and diet

In addition to taking medications for hiatal hernia, treatment involves prescribing a diet, adjusting the daily routine, and traditional medicine recipes are used as an additional measure.

There are certain diet rules that are recommended to be followed to more quickly eliminate negative symptoms:

Meals should be small, evening meals should be completed several hours before bedtime.
A specialist can prescribe mineral water; preference is given to alkaline waters; they are consumed 30 minutes before meals in a single volume of 100 ml.
The possibility of overeating should be excluded, for which daily calorie counting is carried out - it should not exceed 1800-2000 kilocalories.

A patient with hiatal hernia should avoid using:

Any fatty, fried and spicy foods.
Fatty products made from cow's milk.
Butter and vegetable oil.
Coffee, chocolate and cocoa.
Onions (both green and onions) and garlic.
Coarse fiber found in whole nuts and grains, hard raw fruits and vegetables, bran.
Dishes (including drinks and sauces) made from tomatoes.
Pickles.
Crackers and chips.
Ice cream.
Mustard, ketchup and vinegar.
Any carbonated drinks.

The diet of a patient with hiatal hernia requires the presence of:

Porridges prepared with skim milk or water.
Dishes made from low-fat goat and cow milk.
Lean meat and fish.
Baked or mashed apples.
Fresh bananas.
Baked potatoes and carrots.
Egg whites.
Green peas and green beans.
Steamed broccoli.
Soft cookies.
Baked goods made from rice flour.
Marmalade, marshmallows, jelly and marshmallows.

Since a hiatal hernia occurs against the background of unbearable heartburn, it is necessary to exclude foods that can provoke its occurrence from the patient’s diet. Equally undesirable are drinks and dishes, the consumption of which leads to bloating.

Diagnostics

The main signs of the disease are determined by x-ray examination. To identify an abnormal location of the end of the esophagus and stomach, use:

general visual X-ray examination with contrast of the initial digestive organs - currently rarely used;
X-ray (series of images) of the esophagus and stomach.

The patient is photographed in the following position:

lying down,
standing,
on the side
in the knee-elbow Trendelenburg position.

Radiologists take into account, as a direct sign, a clear displacement of part of the stomach into the chest cavity. Indirect ones include:

disturbed shape of the gas bubble or its absence, change in size;
increase in the angle of His;
signs of reflux reflux;
movements of the esophagus that are the opposite of proper peristalsis.

Ultrasound diagnostic specialists consider it possible to participate in the examination; the picture differs from the radiological signs (right)

Esophagogastroscopy shows:

non-closing walls of the esophagus in the diaphragmatic area (picture of “gaping of the cardia”);
the cardiac section is located higher than usual due to shortening of the esophagus;
gastroesophageal reflux;
foci of proliferation of foreign epithelium.

Endoscopy helps to identify the severity of reflux influence and possible transition to a neoplasm.

Additional methods include:

esophagomanometry,
scintigraphy,
intraesophageal pH-metry.

Conducting a general clinical examination helps to identify complications:

stool analysis can detect early signs of bleeding;
blood test shows anemia, infection;
An ECG is absolutely necessary to exclude atypical angina.

Differential diagnosis is always carried out:

with different types of diaphragmatic hernias;
cicatricial changes in the esophagus;
peptic ulcer;
malignant neoplasm;
disorders associated with increased pressure in the portal vein;
angina pectoris;
gallstone disease.

Gymnastics

For hiatal hernia, physical therapy is recommended. The following exercises help a lot:

Lie on your side and rest your head on the cushion. Inhale deeply and inflate your stomach as much as possible, then exhale slowly and relax. Repeat 4-5 times.
Get on your knees, straighten your back, inhale and slowly bend to the right, exhale and return to the starting position, repeat the exercise 6-7 times.
Lie on your back. Breathing is even and calm. Slowly turn to your left and then to your right side, trying not to lose your breath.

Conservative treatment

Refusal of treatment for a diaphragmatic hernia sharply increases the risk of cancer in the next 5 years. A feature of the tactics for axial hernia of the diaphragm is the absence of urgent indications for surgical treatment, which is explained by the clinical course:

this type of hernia is not strangulated;
can be successfully treated conservatively.

The objectives of conservative treatment are:

prevention of gastroesophageal reflux;
suppression of gastric acidity;
restoration of impaired motility of the esophagus and stomach;
therapy for reflux esophagitis.

Regime and diet

Patients must follow the doctor's recommendations on diet and regimen constantly. It is necessary to avoid lifting heavy objects, performing intense work, wearing tight clothes, and smoking. You should sleep with your head raised.

Nutrition rules remain for life

Meeting dietary requirements can help reduce symptoms:

food should be gentle in terms of mechanical processing (only steamed dishes, pureed, minced);
feeding frequency should be up to 6 times a day; in the evening you can eat 4 hours before bedtime;
Spicy, smoked, salted, fried dishes made from fatty meat, sauces and seasonings (mustard, pepper, mayonnaise) are unacceptable;
alcohol, carbonated drinks, sour juices, strong coffee and tea are excluded.

Medicines

Medicines used:

drugs that normalize the acidity of gastric juice (Almagel, Maalox, Gastal);
agents that regulate motility (prokinetics) and act on the mucous membranes of the esophagus and stomach (Ganaton, Motilium, Trimebutin, Motilak);
group of proton pump inhibitors (Esomeprazole, Omeprazole, Pantoprazole);
H2-antihistamines (ranitidine);
from the group of vitamins, B1, B6, B12 are especially shown;
For pain, non-steroidal drugs (Ibuprofen, Nurofen) are prescribed.

Tablets should be used with caution. In acute cases, injections are preferable, since absorption is impaired due to changes in the mucous membrane. In addition, the negative effects of medications may occur.

Important for the patient

Conservative and surgical treatment of gastric hernia should be performed in special medical institutions that have a high level of diagnostic and surgical support. It is necessary to understand that the operation is performed according to clear indications: when there is a direct threat of esophageal cancer, pain, strangulated hernia, and functional disorders are not amenable to conventional treatment.

In our clinic we offer a whole range of diagnostic and therapeutic procedures. Surgical repair of a gastric hernia is performed laparoscopically, which can immediately reduce the risk of postoperative complications. The length of stay in the hospital after surgery is several days.