Symptoms and treatment of hiatal hernia

Diaphragmatic hernia is more often an acquired disease that occurs as a result of a regular increase in intra-abdominal pressure. Its other definitions are hiatal hernia, hiatal, esophageal. Pathology has no external signs and is often asymptomatic.

Acquired HH is the exit of the abdominal part of the esophageal tube, together with the cardia of the stomach, beyond the diaphragm into the chest cavity. In rare cases, fixation of organs occurs in the area of ​​​​the natural opening of the ligament, which gives specific symptoms of a previously hidden disease.

In children, a fixed hernia is congenital, and such a violation is life-threatening, fatal. But in adults, a hernia of the esophagus is one of the least dangerous types of this group of diseases in terms of consequences and requires surgical treatment in rare cases.

What is a hernia

Hiatal hernia of the diaphragm is a chronic disease with hidden symptoms. There is a violation due to the expansion of the weakened anatomical opening through which the esophagus passes. A hernia is a condition in which the abdominal part of the esophagus protrudes above the diaphragm, and with it the upper segment of the stomach, cardia and part of the intestine.

This is not the most common type of hernia, but many patients do not even suspect that they have HH, and the disease is detected by chance during examination of the gastrointestinal tract or chest cavity.

Normally, the fat layer prevents the exit of the abdominal organs into the chest. When its resorption occurs and part of the liver atrophies, this will be the main factor in the appearance of the disease.

HH occurs in 5% of the population, but is diagnosed during life in only 50-60% of all patients.

The disease leads to dysfunction of the esophagus, stomach, intestines and other vital organs. HH becomes the cause of esophagitis - inflammation of the esophageal mucosa with all its typical manifestations. Often it is this disease that becomes the reason for the examination, then a hernia of the esophagus is diagnosed.

Causes and risk factors

Hernia of the esophagus has the following causes:

1. Weakness of the ligaments that hold the esophagus in the opening of the diaphragm.
2. Regular and frequent increase in intra-abdominal pressure.
3. Violation of the motility of the esophagus and stomach, weakness of the sphincter.

The weakening of the musculoskeletal apparatus is associated with the physiological process of aging, because hiatal hernia is often diagnosed in the elderly. The connective structure atrophies over time, dystrophy occurs, tissue elasticity is lost. The cause of the disease can be a congenital deviation of the connective tissue - Morfan's syndrome. Against the background of involutional factors, the opening of the diaphragm expands, and at the time of a sharp increase in pressure inside the peritoneum, the stomach and esophageal tube bulge into the chest cavity.

Factors in the appearance of HH with a weakening of the ligamentous apparatus of the diaphragm:

• bloating and repeated vomiting;
• sharp inclinations of the body;
• overeating, quick snacks;
• period of pregnancy;
• overweight, obesity;
• frequent and prolonged cough;
• the presence of neoplasms in the abdominal or thoracic cavity;
• trauma to the abdomen and chest;
• heavy physical activity, weight lifting;
• chronic constipation and dropsy.

Such a deviation as dyskinesia, a violation of motor skills, can contribute to HH. The disease accompanies not only a diaphragmatic hernia, but also an ulcer, gastroduodenitis, cholecystitis, chronic pancreatitis.

Congenital diseases of the esophageal tube will also become a factor in the appearance of HH. This may be stenosis, narrowing of the organ due to diverticulum or scarring.

Clinical manifestations

The main form of the course of the disease is asymptomatic. The patient may have a minimal set of rarely appearing signs of a disorder. More often it is heartburn after eating, discomfort during bending and with tension in the muscles of the abdominal wall. During coughing, there may be a sensation of a foreign body. Given that a hernia of the esophagus is often accompanied by reflux esophagitis, the symptoms will be intertwined with inflammation.

With a hernia of the esophagus, the following manifestations of the disease may disturb:

1. Spasmodic pain behind the sternum . This symptom appears with a large hernia, but when the normal function of the esophageal sphincter is still preserved. The pain spreads from the sternum to the stomach, gives to the area of ​​​​the shoulder blades. The clinical picture at the same time resembles exacerbated pancreatitis.
2. Angina . Pain in the region of the heart can be easily confused with sensations during the inflammatory process of the esophageal mucosa. Angina with esophageal hernia is a false symptom that is in no way associated with CCC pathologies.
3. Heaviness and pain after eating fatty foods . This is a specific symptom of HH, which also appears after exercise and in case of bloating.
4. Relief of the condition after a deep breath, belching, single vomiting . The patient also becomes better when changing positions, after a few sips of clean water.

Infringement is a rare complication of diaphragmatic hernia, but this condition is dangerous, accompanied by nausea, vomiting, severe malaise, dizziness.

Compression of the esophagus and stomach leads to severe pain, tachycardia occurs, and vomiting with blood is less common. Infringement is characterized by such phenomena as shortness of breath, lowering blood pressure and cyanosis. Complicated hiatal hernia of the esophagus can lead to internal bleeding.

With concomitant esophagitis, the disease has the following symptoms:

• sour taste in the mouth - the phenomenon is associated with the reflux of the contents of the stomach into the esophagus and then into the oral cavity, often the patient is faced with increased sensitivity of the teeth and stomatitis, which is the result of constant irritation of the bile mucosa;
• frequent belching of sour contents;
• regurgitation - regurgitation occurs more often at night, when a person takes a supine position, a hearty and late dinner provokes this symptom;
• heartburn - a symptom of esophagitis and hernia, occurs in the morning and evening after eating, which is often accompanied by hiccups;
• burning and soreness in the back of the tongue;
• voice change, hoarseness.

Types of disease

There are three types of disease:

1. Axial or sliding HH - organs move freely from one cavity to another when changing the position of the body.
2. Paraesophageal hernia of the esophageal opening of the diaphragm - the fundus of the stomach, together with the esophagus, passes above the diaphragm.
3. Mixed HH - a combination of paraesophageal and sliding type.

Clinical forms of the disease:

• asymptomatic HH;
• congenital short esophagus;
• with cardia insufficiency syndrome;
• without cardia insufficiency;
• in combination with other pathologies of the gastrointestinal tract.

Depending on the development mechanism:

• traction;
• pulsion;
• mixed.

By severity:

• the initial hernia of a mild degree is a weak symptomatic complex, the disease practically does not affect the quality of life, the patient's state of health is satisfactory, the pathology is determined according to radiography, esophagoscopy;
• moderate severity - there are some pronounced symptoms, the condition is unstable, worsens sharply and returns to normal, working capacity is reduced;
• neglected severe hernia is a pronounced clinical complex of the inflammatory process, complications are added.

Axial

Weakening of the muscles of the diaphragm provokes the occurrence of axial protrusion of the POD. This is an unfixed hernia, because the symptoms appear periodically and are mild. Well-being depends on the position of the body, diet and stress on the body. There is a sensation of a foreign body in the esophagus, which is why the patient often coughs, which only exacerbates the severity of the symptom.

The thoracic part of the esophagus and the cardia move freely from one cavity to another. This is the most common type of disease, which is diagnosed in 75% of patients.

Sliding hernias are divided into several types, depending on the location:

• cardiac;
• total-gastric;
• cardiofundal.

Paraesophageal

A hernia of the paraesophageal type is relatively rare. The disease is characterized by the movement of the fundus of the stomach, its large curvature and intestinal loops into the chest cavity.

Structures located above the diaphragm are infringed, which ends in the most unpleasant consequences. First, the peritoneal sac leaves its place, then the fundus of the stomach and its greater curvature. Gradually, without treatment and against the background of a change in pressure, the entire stomach turns out to be above the diaphragm.

This is a dangerous form of the disease, complications of paraesophageal hernia often end in death, given the long asymptomatic course of the disease. The operation will be scheduled immediately when a large part of the stomach is in the chest cavity.

Fixed

With a fixed HH, the cardia of the stomach moves into the chest and remains there without returning to its place. This form of the disease is characterized by invariable and stable symptoms of varying severity.

This is a rare form of the disease, but it often leads to complications and is accompanied by reflux esophagitis. In case of infringement, immediate surgical treatment is carried out.

Non-fixed protrusion is a chronic abnormality in which the abdominal part of the esophagus and cardia migrate from the abdominal to the chest cavity. It is less dangerous, but complications occur, and then surgical treatment is indicated.

stages

The disease proceeds in several stages:

1. The first - a hernia of the 1st degree is determined when only the abdominal part of the esophagus passes through the diaphragm. The dimensions of the opening of the diaphragm still prevent the free passage of the stomach.
2. The second - not only the esophageal tube penetrates into the chest cavity, but also the upper part of the stomach, which remains at the level of the diaphragm.
3. Third - above the diaphragm is the esophagus and the entire stomach.

Research in hernia POD

HH is detected during x-ray diagnostics with contrast. Some forms of hernias, including initial and sliding, are not always visible on the images, so the study is carried out in a supine position, which will allow a more detailed assessment of the position of the organs and the degree of their movement.

Additional studies to identify diaphragmatic hernia:

• esophagomanometry - the method determines the tone of the esophageal sphincter, reveals mild forms of the disease that are not visible on x-rays, sometimes it allows you to fix reflux, but it cannot show a paraesophageal hernia;
• endoscopy - the displacement of the gastric mucosa above the diaphragm is visible, differential diagnosis with gastritis, pancreatitis, cholecystitis is carried out by endoscopic examination;
• esophagogastroscopy - a research method for assessing the lining of the stomach and esophagus, helps to confirm reflux and other possible complications.

How is the treatment carried out

Asymptomatic hernias of 1-2 degrees of severity do not require treatment. After the study, the doctor may prescribe enveloping and soothing drugs to prevent esophagitis. When there are specific manifestations of the disease, drug therapy, physiotherapy, gymnastics and diet are prescribed.

Principles of treatment of HH:

• taking medicines - antacids, antispasmodics, painkillers, enveloping and restorative drugs;
• normalization of nutrition - the exclusion of heavy foods, eating in small portions, eating warm dishes;
• normalization of weight - physical education, frequent walks in the fresh air, swimming, yoga, massage;
• compliance with the regime of work and rest - the exclusion of heavy physical exertion, good sleep, prevention of stressful situations.

With a diaphragmatic hernia, you should avoid leaning forward after eating, try not to overeat and be careful about choosing foods.

Nutritional conditions for HH:

• it is unacceptable to overeat and rush during a meal;
• dinner should be a few hours before bedtime;
• one serving of food should not exceed 300 g;
• after eating you can not go to bed, it is recommended to take walks;
• half an hour after eating you can not squat, bend over, jump.

Conservative therapy

Drug treatment includes taking the following groups of drugs:

• PPIs, proton pump inhibitors - Omeprazole, Esomeprazole;
• H2-histamine receptor blockers - Ranitidine;
• prokinetics to reduce the negative effect of acid on the walls of the esophagus - Motilium, Motilak, Trimebutin;
• B vitamins to restore the mucosa of an irritated esophagus;
• antacids - Gastal, Almagel, Maalox.

Operation

Indications for radical removal of HH will be the following conditions:

• lack of positive dynamics from conservative methods;
• diagnosis of precancerous conditions;
• complicated forms of the disease.

Surgical intervention will be aimed at strengthening the enlarged and weakened opening. For this purpose, crurography with suturing of the legs of the diaphragm and subsequent plasty can be used. The operation can also be performed with the removal of part of the esophageal tube and suturing of the stomach to fix it to the wall of the abdominal cavity.

Complications without treatment

What is dangerous hiatal hernia, which was not detected in a timely manner:

• aspiration pneumonia - reflux causes food particles and mucus to enter the respiratory tract, which can also cause asthma;
• stenosis - narrowing of the esophageal tube occurs due to scarring or perforation, the cause can be an ulcer, chemical and thermal burns;
• bleeding - develops with perforation of the ulcer, which leads to reflux and the lack of adequate drug therapy;
• erosive, catarrhal and ulcerative esophagitis;
• reflex angina.

Preventive measures

Diaphragmatic hernia may result in esophageal cancer in 2 out of 10 patients, but this is influenced by genetic predisposition and comorbidities. To minimize the risks, you should adhere to certain prevention rules that do not differ for each form of the disease.

What is important for the prevention of the consequences of HH:

• give up smoking and alcohol;
• normalize the diet;
• avoid heavy workload;
• arrange a good sleep and rest during the day;
• engage in the health of the digestive and respiratory systems;
• drink non-carbonated mineral water an hour before meals;
• wear loose clothing that does not restrict the stomach and chest.

The disease of the first degree can be cured completely without the need for surgical intervention, but this process is long and difficult.

At the second and third stages, it is extremely difficult to get rid of diaphragmatic hernia, there is a high risk of recurrence. Preventive measures are always needed, regardless of the form and severity, because it is not the hiatal hernia itself that is dangerous, but the complications that it can lead to without adequate therapy.