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Hiatal Hernia: Symptoms, Causes, Diagnosis, and Treatment

source: www.everydayhealth.com

Classification of Hernia

First: internal hernias: occur through the hole inside the body
1. Diaphragm hernia:
Either Congenital (morgagni hernia, Parasternal hernia, often right) (bochdalek, diaphragm hernia, posterior, often left( Or acquired (Hiatal hernia(
2. Hernias within the peritoneum: occur through the hole in the Thorac or mesarica or foramen of Winslow.

Second: External hernias: occur through the hole in the abdominal wall towards the outside:
3. Inguinal hernia (direct, indirect) - Femoral hernia.
4. Linea alba hernia: (Epigastric hernia) - Paraumbilical hernia.
5. congenital Hernia or Postoperative hernias
6. abdominal wall hernia (rare): Spigelian hernia, Lumbar hernia, Obturator hernia.

Areas of anatomical constriction in the esophagus:
Upper esophageal sphincter (swallowing function, anatomical sphincter): 15 cm away from Incisors, the most prone to perforation during upper gastrointestinal endoscopy.
The lower esophageal sphincter (function preventing reflux, a physiological sphincter): is 40 cm away from the Incisors, permanently closed only when swallowing and burping, pressure about 13 mmHg.

Types of Hiatal Hernias

The first type: Sliding hernia (commonest)
About 90% of the Hiatal hernia
The gastroesophageal junction is displaced (The location of Cardia varies), elevation of the angle of Hess and intervention of the chest cavity, caused by chronic high pressure in the abdomen (such as from pregnancy, obesity, coughing, or straining during bowel movements), often not symptomatic, and if demonstrated symptoms have the same symptoms of reflux

Type II: Rolling or paraesophageal hernia:
The gastroesophageal valve remains within the abdomen (without gastric esophageal Displacement), but the oesophageal hole is wide.
The fundus ascends to the chest and is located on the thoracic side of the esophagus, The incidence increases exponentially with age.
Symptoms: Dysphagia (due to the pressure of the fundus on the esophagus), chest pain, fullness, heartburn, belching, reflux, Vomiting Blood (Hematemesis), Aspiration pneumonia, dyspnea.
Note: Women are more infected than men in the previous two types

Type III: mixed:
The hole is very wide and the fundus rises with the gastroesophageal valve into the chest.

Advanced type (type IV): stomach within the chest:
The entire stomach is in the chest, and the stomach rotates 180 degrees around its longitudinal axis.
Symptoms: Excessive bleeding, intestinal obstruction, Gastric torsion, gastric infarction.

Diagnosing a Hiatal Hernia
  • X-ray: useful in paraesophageal hernia and in the chest, while not useful in Sliding hernia.
  • Contrast of radiotherapy of the upper gastrointestinal tract (Barium swallow), is useful in hernia of type II and III and If the Sliding hernia is large
  • The most important method is upper gastrointestinal endoscopy

Treatment for Hiatal Hernias

Sliding hernia: 85% pharmacotherapy and 15% Nissen-type fundoplication.
Rolling or paraesophageal hernia: The treatment is always surgical because of the complications are fatal.

endoscopic-fundoplication-bridges-gap-360-Nissen-type fundoplication
source: www.mayoclinic.org
Patients who are candidates for surgery: Young patients who have reflux with or without deficiency in sphincter.

Principles of Surgery:
  • Return the contents of hernia to the inside of the abdomen.
  • Reset the lower sphincter pressure to twice the pressure of the stomach at rest (the sphincter pressure should be about 30 mmHg), and the sphincter resistance should not exceed the driving force of the esophagus (because this causes permanent dysphagia).
  • Sufficient length of the lower sphincter in the abdomen (at least 2 cm)
  • Allow the relaxation of the Cardia during swallowing, using the fundus and not the body of the stomach to folding.
  • the folding around the bottom of the esophagus and not on the Lesser curvature, because when swallowing food relaxes the fundus and allows the esophagus to move food, and at the height of abdominal pressure press the fundus on the esophagus and close it.  

Results after 360° Nissen-type fundoplication
  • Typical symptoms improve in more than 90% of patients after 2-3 years.
  • Transient dysphagia is common after surgery as a result of surgical edema and automatically disappears after 3 months, mild-grade.
  • Abdominal puffiness: Common, due to increased swallowing seen in patients with reflux.
  • Other complications include spleen injury, pneumothorax, esophageal perforation.

There is also a Thal process that has the same steps as Nissen, but the fundoplications are partial (270° anterior) only around the lateral and front faces of the esophagus.
In addition to the Belsey process, 270-anterior transthoracic fundoplications (Belsey)
source: www.liberaldictionary.com

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