Diaphragmatic-Hernias

Diaphragmatic Hernias

Hiatal hernia is a common disease that causes reflux (GORD). It affects about 20% of people at least once weekly. It is manifested mostly as heart burn. GORD is caused by abnormal exposure of the oesophagus to refluxing gastric acid and bile reflux.

A hiatal hernia occurs when the upper part of the stomach and sometimes other viscera migrate upward through the diaphragmatic hiatus into the chest.

Normally, the oesophagus crosses the diaphragm via the hiatus and enters the abdomen between the two crura of the diaphragm. In patients with hiatal hernias, the opening of the diaphragmatic hiatus is wider than normal which allows a part of the stomach to protrude through the hiatus and into the chest.

The two main types of hiatal hernias are

  • Sliding Hiatal Hernia is the most common type of hiatal hernia, occurring when part of the stomach slides the chest cavity through the hiatus. This occurs due to weakness in the anchors of the oesophagus to the diaphragm, or from increased pressure in the abdomen. In this type of hernia the site of the blower sphincter of the oesophagus migrates up into the chest cavity above the diaphragm.

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  • Para oesophageal Hernia occurs when part of the stomach protrudes through the hiatus, placing it next to the oesophagus. Unlike sliding hernias, para oesophageal hernias remain in the chest at all times. This may lead to strangulation of the stomach that leads to impairment of the stomach blood supply.

 

Risk Factorts:

  1. Age
  2. Obesity
  3. Strenuous physical activity that raises abdominal pressure (heavy weight lifting and sports)
  4. Regular increased pressure in the abdomen from activities like severe coughing, vomiting and straining.

Symptoms:

  1. Heartburn, this particularly occurs after a meal or lying down
  2. Pain or discomfort in the upper abdomen or the chest
  3. Excessive burping
  4. Hoarseness of voice and worsening asthma
  5. Frequent cough and splattering or throat irritation
  6. Chest pain

Investigations:

  • Barium swallow: is an X-ray imaging study in which a barium paste is swallowed . This makes the oesophagus clearly outlined  on the X-ray imaging so the radiologist can study the anatomic details and the functional contractions of the oesophageal muscles, it will also show the hernia and other pathologies of the oesophagus such as cancer and benign strictures.
  • Manometry: is a diagnostic test that utilises a thin catheter that is inserted into the oesophagus to measure pressure, contractions waves and their coordination and the ability of the lower sphincter to relax  to with swallowing. Impedance test can monitor how effective the oesophageal contractions clear liquids to the stomach.
  • Endoscopy: is a day procedure under sedation, a fibro-optic camera is inserted for direct visualisation of the inner lining of the oesophagus, stomach and duodenum. Endoscopy allows doctors to visualise oesophageal disorders, as well as the damage  by GORD, such as the development of a pre-cancerous condition known as  Barrett’s oesophagus an oesophageal cancer. In addition to that, the doctor will be able to diagnose other conditions such as stricture and hiatal hernia.

 Treatment options:

For patients who develop GORD as a result of the hiatal hernia, medications may be recommended to control symptoms. These are  Antacids to neutralise stomach acid, medications that reduce acid production, and/or medications that block acid production and help to heal the oesophagus.

Lifestyle changes that can help to ease the symptoms include; weight loss,  quit smoking , dietary changes (coffee and chocolate make symptoms worse), and elevating the head of the bed.

Surgery:

Sometimes a hiatal hernia requires surgery if symptoms are severe and are not controlled with conservative treatment. Surgery is also necessary in emergency situations, particularly when the hernia is incarcerated causing an obstruction to the gastric outlet. Also when there is suspicion of twisting of the stomach that can cut the blood supply to the stomach.

Surgical treatment for hiatal hernias is usually undertaken laparoscopically. The stomach is pulled down into the abdomen, the peritoneal sac of the hernia is removed and repair is done to the opening in the diaphragm  by suturing with or without a mesh; which helps to reconstruct the oesophageal sphincter. This minimally invasive approach allows the surgeon to perform complex surgery using small incisions and a camera. It also allows for a shorter hospital stay, less postoperative pain and faster recovery.

 

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Hiatal hernia surgery is often combined with surgery for GORD, particularly if the patient has been suffering from reflux, is complicated, or has been unresponsive to medication therapy. During this procedure part of the upper stomach is wrapped around the lower sphincter to augment the pressure at the sphincter and further prevent reflux.

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