Hiatal Hernia

Hiatus or hiatal hernia is a defect in the diaphragm that permits a portion of the stomach to pass through the diaphragmatic opening into the chest. Three types of hiatal hernia can occur: sliding hernia, paraesophageal ("rolling ") hernia, and mixed hernia, which includes features of both.

In a sliding hernia, both the stomach and the gastroesophageal junction slip up into the chest, so that the gastroesophageal junction is above the diaphragmatic hiatus. In paraesophageal hernia, a part of the greater curvature of the stomach rolls through the diaphragmatic defect. Treatment can prevent such complications as strangulation of the herniated intrathoracic portion of the stomach.

Causes

Hiatal hernias are caused by a weakness in the muscle tissue at the opening in the diaphragm where the esophagus passes through to the stomach. In some people, this weakness is congenital, which means it is present at birth. In others, it develops over time, as a result of excessive weight gain, physical activity that places pressure on the abdomen, pregnancy, heavy lifting, straining during bowel movements because of constipation, severe vomiting, or chronic and intense coughing. Because the muscle is weak, the hernia occurs during abdominal strain.

Signs and symptoms

The most common symptom is burning in your chest (heartburn), especially at night when you are lying down. Other possible signs include burping and trouble swallowing.

A hiatal hernia by itself rarely causes symptoms -- pain and discomfort are usually due to the reflux of gastric acid, air, or bile. This happens more easily in the presence of hiatal hernia.

Diagnosis

Hiatal hernia is diagnosed based on typical clinical features and the results of the following laboratory studies and procedures:

• Barium swallow x-ray
• Esophagogastroduodenoscopy ( EGD )

Treatment

The primary goals of hiatus hernia treatment are to relieve symptoms by minimizing or correcting the incompetent cardia and to manage and prevent complications. Medical therapy is used initially because symptoms usually respond to it and hiatal hernia may recur after surgery.

Medical therapy : - Medical therapy attempts to modify or reduce reflux by changing the quantity or quality of refluxed gastric contents, strengthening the LES muscle pharmacologically, or decreasing the amount of reflux through gravity.

Specific measures include restricting any activity that increases intra-abdominal pressure (coughing, straining, bending), giving anti emetics and cough suppressants, avoiding constrictive clothing, modifying diet, giving stool softeners or laxatives to prevent straining during defecation, and discouraging smoking because it stimulates gastric acid production.

Modifying the diet means eating small, frequent, bland meals at least 2 hours before lying down (no bedtime snacks); eating slowly; and avoiding spicy foods, fruit juices, alcoholic beverages, and coffee. Antacids also modify the fluid refluxed into the esophagus and are probably the best treatment for intermittent reflux.

To reduce the amount of reflux, the overweight patient should lose weight to decrease intra-abdominal pressure. Elevating the head of the bed about 6" (15 cm) reduces gastric reflux by gravity.

Drug therapy to strengthen cardiac sphincter tone may include a cholinergic agent such as bethanecol. Metoclopramide has also been used to stimulate smooth-muscle contraction, increase LES tone, and decrease reflux after eating.

Surgery :- Failure to control symptoms medically or the onset of such complications as stricture, bleeding, pulmonary aspiration, strangulation, or incarceration necessitates an antireflux surgical repair.

Surgery creates an artificial closing mechanism at the gastroesophageal junction to strengthen the LES's barrier function. A transabdominal fundoplication is performed by wrapping the fundus of the stomach around the lower esophagus to prevent reflux of stomach contents. An abdominal or a thoracic approach may be used. Laparoscopic surgery to repair the hernia is now commonplace.

Hiatal Hernia Diet Tips

About 50% of all people with hiatal hernias do not have any symptoms. For the other approximate 50% of individuals with hiatal hernias who do have symptoms, heartburn is the most common symptom. Knowing how to control the heartburn through diet is important.

A few quick tips about eating with a hiatal hernia:

• Eat smaller, more frequent meals, instead of larger meals
• Don't eat for at least two hours before bedtime
• Sit up for at least one hour after eating
• Omit caffeine from your diet
• Don't bend over right after eating
• Avoid spicy foods
• Avoid alcohol & smoking

Prevention

Some hernias can be prevented by maintaining a reasonable weight, avoiding heavy lifting and constipation, and following a moderate exercise program to maintain good abdominal muscle tone.