Hernia

Introduction

  • A hiatus hernia occurs when part of the stomach pushes up through the diaphragm into the chest cavity through the oesophageal hiatus.
  • It is often associated with gastro-oesophageal reflux disease (GORD) and may cause heartburn, regurgitation, or chest discomfort.
  • Management includes lifestyle modifications, medications, and in severe cases, surgery.

Types of Hiatus Hernia

  1. Sliding Hiatus Hernia
    • The stomach and the lower oesophageal sphincter (LOS) slide into the chest.
    • Most common type (over 90% of cases).
  2. Paraesophageal (Rolling) Hiatus Hernia
    • The stomach pushes into the chest beside the oesophagus.
    • Less common but may lead to complications like strangulation.
  3. Mixed Hiatus Hernia
    • Combination of sliding and paraesophageal hernia.

Causes of Hiatus Hernia

  1. Increased Intra-Abdominal Pressure
    • Chronic coughing, heavy lifting, pregnancy, obesity.
  2. Weakening of Diaphragmatic Muscles
    • Age-related changes or congenital abnormalities.
  3. Trauma or Surgery
    • Previous injuries or surgeries affecting the diaphragm.
  4. Lifestyle Factors
    • Poor posture, overeating, or smoking.

Symptoms of Hiatus Hernia

  1. Common Symptoms
    • Heartburn and acid reflux.
    • Regurgitation of food or acid into the mouth.
    • Difficulty swallowing (dysphagia).
    • Chest pain or discomfort.
  2. Severe Symptoms (Rare)
    • Shortness of breath (due to pressure on the lungs).
    • Vomiting blood or passing black stools (indicating bleeding).
    • Acute chest pain from gastric volvulus (twisting).

Complications of Hiatus Hernia

  • Strangulation: Reduced blood supply to the herniated stomach, leading to tissue death.
  • GORD and Oesophagitis: Chronic reflux causing inflammation of the oesophagus.
  • Barrett’s Oesophagus: Precancerous changes in the oesophageal lining.
  • Anaemia: Chronic blood loss leading to iron-deficiency anaemia.

Diagnosis of Hiatus Hernia

  1. Medical History and Physical Examination
    • Focus on reflux symptoms and risk factors.
  2. Imaging and Diagnostic Tests
    • Barium Swallow X-Ray: Visualizes the herniated stomach.
    • Endoscopy: Identifies inflammation, ulcers, or Barrett’s Oesophagus.
    • Manometry: Measures LOS function and oesophageal motility.
    • 24-hour pH Monitoring: Evaluates acid reflux severity.

Treatment Options for Hiatus Hernia

1. Lifestyle Modifications

  • Dietary Changes
    • Avoid large meals, acidic foods, and caffeine.
    • Stay upright for at least 2 hours after eating.
  • Weight Management
    • Reducing body weight can decrease abdominal pressure.
  • Smoking Cessation
    • Improves LOS function and reduces reflux.
  • Postural Adjustments
    • Elevate the head of the bed by 6–8 inches.

2. Medications

Drug ClassExampleBrand NameManufacturerCost Range
AntacidsAluminium HydroxideGavisconReckitt Benckiser$5–$15 per bottle
H2 Receptor BlockersRanitidineZantacGSK$10–$20 per pack
Proton Pump Inhibitors (PPIs)OmeprazolePrilosecAstraZeneca$10–$25 per pack
EsomeprazoleNexiumAstraZeneca$15–$30 per pack
  • Antacids: Neutralize stomach acid for quick symptom relief.
  • H2 Blockers: Reduce acid production.
  • PPIs: Most effective for long-term acid suppression.

3. Surgical Treatments

  • Nissen Fundoplication
    • Wrapping the upper stomach around the oesophagus to strengthen the LOS.
  • Laparoscopic Repair
    • Minimally invasive surgery to reduce the hernia and repair the hiatus.
  • LINX Device
    • Magnetic ring placed around the LOS to prevent reflux.

4. Alternative and Supportive Therapies

  • Herbal Remedies
    • Ginger or chamomile tea may soothe symptoms.
  • Physiotherapy
    • Core-strengthening exercises to reduce intra-abdominal pressure.

Monitoring Parameters

  • Monitor symptom relief and medication side effects.
  • Regular endoscopy for patients with Barrett’s Oesophagus or severe GORD.
  • Weight and dietary habits to evaluate lifestyle modification effectiveness.

Patient Counseling Points

  • Explain the chronic nature of hiatus hernia and the importance of long-term management.
  • Emphasize adherence to dietary and postural recommendations.
  • Educate on the potential side effects of medications and the importance of follow-ups.
  • Discuss the risks and benefits of surgical options for severe cases.

Use in Children

  • Rare but may occur; conservative management is typically sufficient.

Use in Pregnancy

  • Symptoms often resolve postpartum; antacids and H2 blockers are generally safe.

Use in Elderly

  • Monitor for complications like anaemia or severe reflux; adjust treatments for comorbidities.

FAQs About Hiatus Hernia

Q1: What causes a hiatus hernia?

  • Weak diaphragmatic muscles, increased abdominal pressure, and lifestyle factors.

Q2: Can a hiatus hernia be cured?

  • Surgery can repair severe cases; mild cases are managed with medications and lifestyle changes.

Q3: Is a hiatus hernia dangerous?

  • Most are not, but complications like strangulation can be serious.

Q4: What are the common symptoms of hiatus hernia?

  • Heartburn, regurgitation, and chest discomfort.

Q5: How is a hiatus hernia diagnosed?

  • Through barium swallow X-rays, endoscopy, and pH monitoring.

Q6: Can weight loss improve symptoms?

  • Yes, reducing abdominal pressure can significantly relieve symptoms.

Q7: What foods should I avoid with a hiatus hernia?

  • Spicy foods, caffeine, chocolate, and fatty meals.

Q8: Is surgery always required for hiatus hernia?

  • No, most cases are managed with lifestyle changes and medications.

Q9: Can a hiatus hernia cause difficulty swallowing?

  • Yes, especially in severe cases with significant oesophageal irritation.

Q10: Can stress worsen symptoms?

  • Yes, stress can exacerbate reflux symptoms.

Q11: Are there exercises for hiatus hernia?

  • Yes, core-strengthening exercises may help but should be done under guidance.

Q12: Can I lie down after eating with a hiatus hernia?

  • No, it is best to stay upright for at least 2 hours.

Q13: How long does recovery take after surgery?

  • Most patients recover within a few weeks, but complete healing may take longer.

Q14: Is it safe to take PPIs long-term?

  • Long-term use is generally safe but requires monitoring for side effects like osteoporosis.

Q15: Can hiatus hernia recur after surgery?

  • Yes, especially if lifestyle modifications are not maintained.