Hiatus hernia is defined as presence of a pouch of gastric mucosa within thoracic cage.
- It is commonly seen in middle aged obese females.
- May be congenital.
- May be due to conditions which raise intra-abdominal pressure like obesity, pregnancy, ascites or abdominal tumors.
- May follow surgical operations like partial gastrectomy or vagotomy.
Types And Symptoms Of Hiatus Hernia
- Sliding type- this is the commonest variety. In this type there is a simple upward slide of stomach with esophago-gastric junction through the hiatus into the chest.
- Rolling type- in this type, esophago-gastric junction is within abdominal cavity, but part of gastric fundus protrudes through the hiatus into the chest.
Symptoms Of Hiatus Hernia
Symptoms due to reflux.
- Retro-sternal chest pain which is aggravated by stooping or lying down soon after meals.
- Heart burn or regurgitation of acid fluid.
- Dysphagia (pain while swallowing) due to esophageal muscle spasm or esophagitis.
Symptoms due to pressure- either due to dilated esophagus and or gastric pouch on surrounding structures.
- From pressure on mediastinum- dyspnoea (difficulty in breathing), palpitation, cough and anginal pain.
- From pressure on diaphragm- hiccup, spasmodic pain.
Diagnosis For Hiatus Hernia
- X-ray chest- if a sliding hernia is large, it may be seen as retro-cardiac shadow with fluid level.
- Barium swallow to assess hernia size and development of complications.
- Endoscopy and biopsy- mainly of value in assessment of esophagitis and consequent bleeding, ulceration and stricture formation.
Medical Treatment For Hiatus Hernia
- To minimize gastro-esophageal reflux
- Elevate bed head by 20cm.
- Avoid posture precipitating the reflux e.g. bending, stooping etc.
- Avoid large meals.
- No food or drinks for 3-4hrs before bedtime.
- Reduce weight if obese.
- No smoking.
- Avoid all non-steroidal pain killers.
- Avoid foods which provoke symptoms e.g. coffee.
- Reduce gastric acidity and pepsin secretion with ranitidine or famotidine and other antacids.
- Increase tone of lower esophageal sphincter with drugs like metoclopramide and domperidone.
Hiatus Hernia Surgical Treatment
Surgery consists of restoration of intra-abdominal segment of esophagus into abdomen, repairing the hiatus and enveloping lower esophagus by gastric fundus (fundoplication).
Indications of surgery
- No relief with conservative treatment.
- Development of complications like peptic ulcer, esophagitis or strangulation of hernia.
- Nocturnal aspiration of regurgitated material into lungs causing pneumonia.
