Hiatus is a defect in an anatomical structure, and oesophagal hiatus is a hole in the diaphragm through which oesophagus passes from the thorax into the abdomen. It occurs when part of stomach projects into the thoracic cavity through or along the side of the oesophagal hiatus of the diaphragm.
The phrenico- oesophagal membrane usually covers the lower end of the oesophagus and attaches it to the diaphragm, thereby preventing gastric herniation through oesophagal hiatus into the thorax. When the phrenico-esophageal membrane is deficient or weak, an axial herniation may develop into the thoracic cavity.
Types of Hiatal Hernia
Sliding Hiatal Hernia: The gastro-esophageal junction ascends towards thorax from the abdomen. This amounts to 95% of the cases and is usually symptomatic. (Fig.A)
Para-oesophagal or Rolling Hiatal Hernia: In this type of a hernia, the entire stomach or a part of it (antrum, cardia, fundus or body) herniates into the thorax, adjacent and towards the left side of the gastro oesophagal junction, which remains intact. In this very kind, GERD may not be pronounced. (Fig.B)
Mixed Hernia – It is a combination of type I and type II and is characterised by the herniation of greater curvature of the stomach as well as gastroesophageal junction into the thorax. (Fig.C)
Hiatal Hernia with abdominal content: It is a type of a hiatal hernia in which intra-abdominal contents, other than or in addition to the stomach, herniates through the hiatus. Typically, these hernias are large and contain organs such as spleen or duodenum. (Fig.D)
Risk Factors of Hiatal Hernia
Risk factors for a hiatal hernia are same as that of GERD. These causative factors contribute to increased gastric pressure and allow for structural changes in the oesophagus leading to a hiatal hernia. Let us have a look at the risk factors below:
- Genetic predisposition
- Positive family history
- Dry mouth or persistent dysphagia
- Connective tissue disorders
- Use of spicy and oil-rich food
- Tea and caffeine
Signs and Symptoms
The signs and symptoms of type I a hiatal hernia mimic those of GERD, because of the herniation of stomach and the reflux of acidic contents into the oesophagus. Thus, type I will present with:
- Chest pain centred to the middle of sternum
- Sour taste in the mouth especially on lying down
- Dry cough
- Vomiting (acid reflux)
- Sensation of lump or food bolus in the throat
- Extra oesophagal presentations of GERD: Asthma, chronic cough and laryngitis
An obstructed or strangulated hiatal hernia will present with the following symptoms:
- Chest pain or pressure (may be confused with an MI)
- Difficulty swallowing
- Coughing ( persistent dry cough)
- Belching excessively
Although asymptomatic, type I may aggravate. The cause of concern arises when a patient experiences one of the following symptoms:
- Chest pressure or pain described as “crushing” in nature
- History of heart disease or risk factors such as diabetes, smoking, raised cholesterol, high blood pressure, older than 55 years, male gender and African American ancestry
- Vomiting blood (Hemetesis)
- Dark, tarry stools (Melena)
- Shortness of breath
- A cough and fever
- Inability to swallow solid food or liquids quickly (Progressive dysphagia)
Complications of a hiatal hernia
- Barrett’s oesophagus
- Esophageal carcinoma
- Oesophagal perforation and bleeding
Investigations and physical examination
- A detailed history
- A complete physical exam
- A rectal exam
- Stool test for occult bleeds
- Blood CP
- Electrocardiogram (ECG)4 to rule out cardiac causes of chest pain
- Chest X-ray to rule out pneumonia, atelectasis, etc.
- Infection (a raised neutrophil count is suggestive of infections)
- Barium swallow
- Upper GI Endoscopy may be performed by a qualified gastroenterologist to obtain a biopsy
The other types of a hiatal hernia are usually asymptomatic and do not present any active complaints.
Sliding hiatal hernia presents with symptoms of GERD and is treated along the same lines.
- High dose antacids
- H2- receptor blockers
- Proton Pump Inhibitors (drug of choice)
PPIs mostly relieve the symptoms of GERD, but in a fraction of patients, the treatment yields poor results. Surgery is considered in patients who experience the following:
- Failed medical treatment
- Patient’s preference: opt for surgery despite successful medical management (due to the quality of life considerations, a lifelong need for medication intake, expense of medicines, etc.
- Complications of GERD (e.g., Barrett’s oesophagus with dysplasia, peptic stricture)
- Extraesophageal manifestations (asthma, hoarseness, cough, chest pain, aspiration)
Surgical treatment can be performed either by laparoscopy or open surgery. The aim of the surgical treatment is to create an intra-abdominal oesophagus, aural repair and some form of wrapping of the stomach around the oesophagus to overcome the reflux (fundoplication).
This surgery comprises of constriction of the lower oesophagal sphincter to prevent reflux by covering the top of the stomach around an exterior of the lower oesophagus. Nissen describes the procedure as 360-degree fundoplication around the lower end of the oesophagus for a distance of 4-5cm (as shown on the picture on next page). Although it provides very good control of reflux, it is associated with over competent cardiac portion leading to dysphagia and gas bloat syndrome. In gas bloat syndrome, the stomach fills with air as belching becomes impossible due to over competent cardiac part of the stomach. The patient feels full after a meal and passes excessive flatus.
Partial fundoplication is carried out to avoid over-competency of the cardiac part, which involves the 270-degree gastric fundoplication around the distal 4cm of the oesophagus. Partial fundoplication can be performed posteriorly (Toupet) or anteriorly (Watson). It has fewer side effects as compared to total fundoplication but the failure rate is higher.
This device is a loop of small magnetic titanium beads hugging the intersection of stomach and oesophagus. The magnetic pull between the beads is solid and keeps the sphincter closed, but allows food to pass through. It can be fixed using laparoscope. New studies show improvements in this procedure.