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HIATAL HERNIA

 

Much is described about the contribution of hiatal hernia to reflux disease, yet all who have a hiatal hernia do not suffer from GERD.  A hiatal hernia is a condition where part of the stomach "slips up" through the hole in the diaphragm into the chest cavity.  The diaphragm is that thin wall of muscle that separates the chest from the abdominal cavity and assists in breathing.  The esophagus, or food-tube, goes through a small hole in the diaphragm, called the diaphragmatic hiatus, into the stomach. Under normal conditions, the esophagus-stomach (esophagogastric, or "EG")  junction lies right at or near the diaphragm.  When you sneeze, cough, or otherwise increase the pressure inside the abdomen, the diaphragm muscles help "pinch" the EG junction shut, and is an important barrier to the reflux of stomach acid into the esophagus.  When that anatomic relationship changes in a hiatal hernia, this important anti-reflux function is lost.

There are several different types of hiatal hernia.  By far the most common is the central sliding type.  As pictured, the stomach slides up along the axis of the esophagus, displacing the EG junction upwards.  These vary in size from very small, to very large.  In a very large size central hiatal hernia, fifty percent or more of the stomach lies in the chest.  Most often these large hiatal hernias require surgery.  However, the vast majority of hiatal hernias are small and do not require surgery.  The symptoms that these small hiatal hernias generate can most often be controlled by dietary and lifestyle changes, as well as limited courses of antireflux medication (see GERD). The other major type of hiatal hernia is the paraesophageal hiatal hernia. In this condition, part of the stomach slides up alongside the esophagus through the diaphragmatic hiatus.  Because of the risk of the stomach getting pinched or twisted in this condition, the vast majority of paraesophageal hernias require repair with surgery.

The cause of hiatal hernia is not known.  They are found most often in people after middle age, in overweight women, and in smokers. Most people with hiatal hernias never have any symptoms.  In many the diagnosis is made while imaging tests such as Barium X-ray (upper GI series), CT scan, endoscopy, or X-ray are being done. Hiatal hernias in and of themselves do not predispose to cancer.  However, in many with hiatal hernia, dangerous, long-standing reflux can occur.  This can lead to Barrett's esophagus, a premalignant (precancerous) condition.

More surgical options for hiatal hernia are available today than ever before.  The traditional surgical approach to fixing a hiatal hernia is open surgery, with recovery times that can take many weeks.  However, a new approach, laparoscopic hiatal hernia repair, is becoming increasingly available.  This uses small incisions and videolaparoscopes to fix the hernia. Hospitalization and recovery times are often much shorter for laparoscopic surgery when compared to open surgery.  While complications can occur during or after any surgery, laparoscopic hiatal hernia repair is being offered more and more to fix both central sliding as well as paraesophageal hiatal hernias.  Not all patients are candidates for hiatal hernia repair. Also, with new, more powerful medicines available for treating reflux disease, many more people are symptom free on medical therapy with appropriate changes in lifestyle today than were ever before.  Your health care professional is the best person to help you decide the right approach for your specific condition.