What is a hiatal hernia?
In a hiatal hernia, parts of the stomach enter the chest cavity through a gap in the diaphragm. The passage for this is the so-called “hiatus”. Normally, the thoracic and abdominal organs are separated by the diaphragm and the esophagus enters the abdomen through a narrow gap in the diaphragm. In the area of this gap, the esophagus and stomach are normally well fixed. In hiatal hernia, however, this connective tissue holding apparatus is so slack that parts of the stomach can slip up through the gap. Also, the constant sliding up and down of the stomach can cause the diaphragmatic gap to become larger over time. Hiatal hernia often occurs in combination with heartburn and gastroesophageal reflux disease.
What are the types of diaphragmatic hernia?
Doctors distinguish between different forms of hiatal hernias:
- Axial hiatal hernia (axial sliding hiatus): In this form of hiatal hernia, the entrance to the stomach and the upper part of the stomach slip through the diaphragm into the chest cavity.
- Paraesophageal hiatal hernia: paraesophageal hiatal hernia occurs less frequently than axial hernia. In this type of diaphragmatic hernia, parts of the stomach also enter the chest cavity through the diaphragm. However, the peritoneum and the connective tissue suspension ligaments between the stomach and the diaphragm are very much “worn out” and form a kind of sac that rests on the diaphragm next to the esophagus. “Paraesophageal” means “next to the esophagus.” Paraesophageal hernias can become very large, so that even the entire stomach slides into the chest cavity (upside-down or thoracic stomach).
- Mixed axial and paraesophageal hiatal hernia: Mix ed forms of axial and paraesophageal hiatal hernia are also possible.
The most common form of hiatal hernia is axial hiatal hernia. Nine out of ten people with a hiatal hernia have an axial hernia. In most cases, it causes little or no discomfort. Symptoms occur when the valve mechanism between the esophagus and stomach no longer functions properly due to the altered position of the entrance to the stomach, and acidic stomach contents enter the esophagus.
Hiatal hernia and gastroesophageal reflux disease
Hiatal hernia is often associated with the so-called reflux disease. In reflux disease, gastric juice flows back into the esophagus (reflux = backflow). The angle at which the esophagus opens into the stomach plays a role. Normally, the esophagus is at an acute angle to the stomach (so-called His angle). However, when the connective tissue holding apparatus loosens in the area of the esophageal junction, the angle changes. Now gastric juice can flow back into the esophagus more easily. The result is reflux symptoms such as heartburn or belching. The so-called cardio-fundal malposition is a frequent incidental finding during gastroscopy. It is considered a precursor to a diaphragmatic hernia. In the case of a diaphragmatic hernia, the acute angle between the esophagus and stomach is then completely eliminated.
Hiatal hernia: causes and risk factors
A hiatal hernia is caused by a weakening of the connective tissue holding apparatus in the area of the esophagus. Some people have naturally weaker connective tissue. With age, this can develop into a diaphragmatic hernia. Increased pressure in the abdomen on the diaphragm can also increase the risk of hiatal hernia. For example by:
- Frequent pressing (e.g. with constipation)
- Chronic cough
- Obesity
- Pregnancy and birth
Symptoms: Hiatal hernia often without signs
A hiatal hernia often does not cause any discomfort. Many people do not know that they have a hiatal hernia.
Axial hernia: typical symptoms are often absent
An axial hernia rarely causes discomfort. It is often an incidental finding, such as during a gastroscopy or x-ray. It is generally considered to have little or no disease value. If the hiatal hernia is accompanied by gastroesophageal reflux disease, aggressive gastric juice can flow back into the esophagus. This leads to symptoms such as:
- Heartburn
- Air burst
- Difficulty swallowing
- Resuspension of food residues
Paraesophageal or mixed hernia: symptoms may increase in progression
A paraesophageal hernia located next to the esophagus does not necessarily cause symptoms. However, if the disease progresses, it goes through several stages:
- Symptomless stage: In this first, asymptomatic stage, paraesophageal hernia does not cause any symptoms.
- Uncomplicated stage: In this stage, the first symptoms occur, such as difficulty swallowing, heartburn, belching or a pressing feeling in the heart area. The symptoms occur especially after eating. If the hernia is very large, it can also lead to shortness of breath or cardiac arrhythmia.
- Complication stage: paraesophageal hernia can lead to various complications. These include bleeding, stomach ulcers or a ruptured stomach wall. Also, the stomach, which has slipped up into the chest cavity, can become acutely trapped in the diaphragmatic gap. The symptoms then range from a feeling of pressure after eating to severe sudden pain in the chest and upper abdomen. In addition, there is poor performance, pallor and palpitations. Acute bleeding is also possible at this advanced stage.
Hiatal hernia: diagnosis with us
A hiatal hernia is often an accidental diagnosis, because the hernia usually causes no discomfort. The doctor can sometimes detect a large hiatal hernia on an X-ray of the chest (chest X-ray). In the case of typical complaints, we can then determine whether a diaphragmatic hernia is the trigger by means of various examinations. Possible examinations include:
- X-ray examination with contrast medium (esophageal swallow)
- Endoscopy of the esophagus, stomach and duodenum (endoscopy)
- Computed tomography (CT)
- Functional examinations of the esophagus such as long-term acid measurement and pressure measurement
Esophageal swallow: X-ray with contrast medium
During the esophageal swallow, we X-ray the entire swallowing act from the throat to the stomach. For this purpose, the person concerned must drink a contrast medium. With the help of this examination, we can determine what type of fracture it is and how big it is.
Endoscopy: mirroring of the upper digestive tract
During endoscopy, we insert a thin tube through the mouth into the upper digestive tract. The end of the hose is equipped with a small camera. In this way, we can take a direct look at the esophagus, stomach and duodenum and detect inflammatory changes or abnormalities in the digestive tract. Before the procedure, you will be given a sedative so that you will not notice anything about the examination.
Computed tomography
Computed tomography can detect very large hiatal hernias. During this examination, X-ray slides of the body are taken and the hernia can be easily visualized.
Functional examinations of the esophagus (pH-metry, manometry)
These examinations play a role in the diagnosis of gastroesophageal reflux disease (heartburn). They provide information on whether the closure valve between the esophagus and stomach is working and whether too much acid is flowing back from the stomach into the esophagus.
Diaphragmatic hernia: prevention, early detection, prognosis
If you suffer from reflux symptoms, there are a few things you can do yourself to alleviate the discomfort:
- Watch your weight and lose weight if you are overweight.
- Do not eat meals late in the evening.
- Refrain from possible triggers such as sweet foods, acidic drinks, nicotine and alcohol.
- Sleep with raised headboard on the bed
Hiatal hernia: course and prognosis
Many diaphragmatic hernias cause little or no discomfort. If surgery is necessary, then the symptoms usually go away completely after the surgical correction of the hiatal hernia.
Course axial sliding hernia
Prolonged reflux symptoms should always be taken seriously and clarified by a doctor. It is not healthy for acidic stomach contents to regularly flow back into the esophagus because of a hiatal hernia. Reflux can cause ulcers to form on the lining of the esophagus. Inhalation of gastric juice into the lungs (so-called aspiration) can also lead to chronic coughing and considerably increase the symptoms in asthma patients.
Course paraesophageal hernia
Paraesophageal hernia can lead to various complications, for example:
- The unnatural position of the stomach can hinder the normal onward transport of food. Difficulty swallowing or rising of stomach contents are the typical consequences.
- Paraesophageal hernia can lead to inflammation of the gastric mucosa, ulcers and bleeding. Chronic anemia is the typical consequence. In the worst case, an ulcer leads to a breach in the stomach wall (perforation).
- Slipped parts of the stomach can be so severely pinched that blood flow to the tissue is restricted. In those affected, this becomes noticeable in the form of sudden severe chest pain. In the event of incarceration (pinching), immediate surgery is required, otherwise there is a risk of gastric rupture.