It can be silent or associated with symptoms of gastroesophageal reflux. Lifestyle changes, medications and surgery can fix it.
Hiatal hernia is a disorder that affects the stomach; According to estimates, it affects about one in ten Italians and occurs more often with advancing age, but it can also be present in children (during pregnancy the so-called congenital diaphragmatic hernia can be diagnosed in the fetus).
It consists of the migration of a portion of the stomach from the abdomen into the ribcage through a hole naturally present in the diaphragm (which separates the abdominal viscera from the thoracic ones), called esophageal diaphragmatic hiatus (or more simply esophageal hiatus).
This condition can be completely asymptomatic or can give some disorders, mostly gastric (such as heaviness and heartburn, belching, difficulty in swallowing, etc.) due to the ascent of gastric juices from the stomach to the esophagus or, sometimes, even cardiac (such as tachycardia). When it gives health problems it must inevitably be addressed: the options are not lacking.
Not a single hiatal hernia
There are basically three different types of hiatal hernia. “The most frequent and common type of hernia (it concerns about 90 percent of cases), is the so-called slip hernia, which consists in the passage of the connection point of the digestive tract between the esophagus and the stomach and a part of the latter in the thoracic cavity through the esophageal hiatus,” explains Luca Pecchioli, gastroenterologist, head of the digestive endoscopy service of the Italian Neurotraumatological Institute of Grottaferrata (Rome).
Under normal conditions the esophagus, which is largely located in the chest cavity, exceeds the diaphragm (which acts as a watershed between the abdomen and chest) passing through the esophageal hiatus and immediately after connects to the stomach, which is instead completely positioned in the abdominal cavity. When the gastro-esophageal connection point is pushed up through the hiatus carrying with it a part of the stomach, we speak of slip hernia.
This condition is not stable and the stomach tends to return autonomously to its natural anatomical position and then undergo a hernia again: “Repeated sliding can favor over time the exhaustion of the cardia (the valve that normally prevents the acidic gastric material from flowing back into the esophageal duct) which favors the appearance of gastroesophageal reflux associated with the hernia”, explains the gastroenterologist.
In 5 percent of cases, the hiatal hernia is paraesophageal: “In this case the point of connection between the stomach and esophagus and the cardia remain in the abdominal cavity, while to move through the hiatus is only an upper part of the stomach (the gastric fundus), following a rotation of the same” continues Pecchioli. Unlike the previous one, this hernia is stable and, therefore, is not associated with weakness of the cardia, but the part of the stomach that hernia can undergo compression.
“Even rarer, finally, is the hiatal hernia due to a congenital defect of the esophagus, which is shorter than normal,” adds the expert.
Risk factors
For a hiatal hernia to occur, the walls of the esophageal hiatus must lose tone. “This is normally favored by all those conditions that determine an increase in abdominal pressure, such as carrying out intense physical efforts (for example the practice of body building and weightlifting) or prolonged problems of constipation (the effort to defecate contributes to increasing pressure), forms of chronic cough (also due to the habit of smoking) or, again, abdominal trauma (for example as a result of accidents)» explains Pecchioli.
Pregnancy is also a risk factor, because the presence of the fetus contributes to changing intra-abdominal pressure. Obesity also predisposes to hiatal hernia: visceral fat, in fact, ends up pressing on the structures involved. “Long-overweight patients can have hernia problems even after an important weight loss diet, because the action in a certain way containing fat on the now weakened esophageal hiatus is lacking”, adds the expert.
“We must not forget, moreover, that there may be a laxity of the connective tissues of the esophageal hiatus congenital or that manifests itself as a consequence of the natural aging process of the organism“.
Symptomatology
In about one case out of two the hiatal hernia is silent, so much so that the subjects live with it for most of life unconsciously, discovering it only during control examinations carried out for other reasons.
“In other cases, however, it is associated with some symptoms. One of the most common, gastric type, is the tendency to frequent belching, often mistaken for a normal difficulty in digestion. In addition, when the hernia relaxes, usually after meals, it can touch the right ventricle, thus activating extrasystoles, that is, palpitations » explains the specialist.
Often, then, the symptoms associated with hiatal hernia are those deriving from a concomitant gastroesophageal reflux, in turn a consequence, in most cases, of a cardial incontinence:
– burning (which is usually felt after meals, especially if you lie down or bend forward, for example to tie shoes), which from the end of the esophagus can go up behind the sternum to the throat
– acid regurgitation and sensation of liquid in the mouth, accompanied by sour or bitter taste (to which in some cases retching or traces of blood in saliva can be added) and excessive salivation
– piercing chest pain that can be mistaken for the symptom of a heart attack.
Reflux is often accompanied by respiratory diseases, such as asthma, bronchitis and chronic cough, and problems in the upper airways, such as laryngitis, hoarseness, gingivitis, bad breath. “Over time, reflux esophagitis can develop, that is, an inflammation of the mucosa of that digestive tract, caused by the material that rises from the stomach,” adds Pecchioli. “In addition, always in relation to acid erosion, a disease may appear, known as Barrett’s esophagus, whereby damaged mucosal cells tend to be replaced, favoring the formation of esophageal tumors”.
In the event that hiatal hernia is associated with the presence of lesions (such as a gastric or esophageal ulcer), anemia may also occur.
Diagnosis
Hiatal hernia can be detected through a simple X-ray of the upper digestive system or with a gastroscopy.
«If the symptoms of reflux are associated with the hernia, it is also advisable to carry out a ph-metry and a manometry» recalls the specialist. Let’s see what they consist of.
Examination | Purpose | Implementing rules |
---|---|---|
pH-metry | It measures the pH, i.e. the level of acidity of the esophagus and, in practice, quantifies the degree of reflux from which you are affected | The person presents fasting to the doctor who inserts a small probe, from the nostril to the oesophagus, connected to a device to be carried to shoulder strap, which records measurements: usually lasts 24 hours, for allow a measurement of the changes in acidity that occur Later in the day. In this way it is also possible to know how many Reflux episodes occur during the measurement |
Manometry | Measure valve muscle pressure and activity cardias and quantify any valvular incontinence | It lasts about 40 minutes, during which the doctor inserts a small tube from the nose to the stomach and slowly withdraws it throughout the esophagus. The tube is connected to a device that records the muscle contractions |
How do we cure it
If the hernia is asymptomatic, even once it has been detected, no treatment should be performed. Otherwise, it is necessary to intervene differently according to the symptoms that occur and their severity.
When they are mild, the remedies essentially consist of some rules of lifestyle and nutrition, which are the same recommended for those suffering only from gastroesophageal reflux, even in the absence of hiatal hernia:
– quit smoking (nicotine helps to relax the muscles of the cardia)
– avoid lying down immediately after meals
– lie down with the head of the bed raised by about ten centimeters (you can use for example extra pillows)
– avoid taking foods or drinks that contribute to worsening reflux, such as chocolate, mint, alcohol, fatty foods, carbonated drinks.
It is also better to avoid all those actions that increase the pressure inside the abdomen, exhausting the cardia: you should therefore not wear tight clothes at the waist, lift heavy objects and perform abrupt push-ups of the torso; Sports activities that promote reflux such as weight lifting and body building are also not recommended. It can also be useful to follow a diet rich in fiber and water, which removes the risk of constipation.
Your doctor may also prescribe specific medications to keep reflux at bay. “Proton pump inhibitors (such as esomeprazole, omeprazole, pantoprazole, lansoprazole and rabeprazole) are generally prescribed. These are antisecretory drugs, which are used to reduce the gastric production of acids, which represent the most important damaging agent contained in the refluxed material.
In combination can be taken, under medical supervision, also antacid drugs, which neutralize the acid secretion of the stomach, and prokinetics, able to favor its emptying.
“Drug therapy can be followed in cycles lasting one month, every two to three months,” explains Pecchioli. “If, however, the reflux also depends on a stress condition that causes a contraction of the pylorus (the valve that separates the stomach from the duodenum), it may be useful to resort to anxiolytic drugs”.
It therefore becomes very important that, during a specialist visit, a correct anamnesis is carried out that helps to understand precisely the cause of the symptoms associated with hiatal hernia and that possible complications are identified or prevented.
«As an alternative to pharmacological treatment, especially in younger patients, you can opt for surgery, the so-called fundoplication. It is performed in laparoscopy and consists of repositioning the stomach in the natural place and creating, with the upper portion, a sort of tie around the esophagus, tightening in order to reduce the incontinence of the cardia» describes the specialist. “It requires a lot of expertise, because you don’t have to tighten too much (otherwise you would prevent the correct passage of food from the esophagus to the stomach) or too little (otherwise the reflux would remain unchanged).”
Joycelyn Elders is the author and creator of EmpowerEssence, a health and wellness blog. Elders is a respected public health advocate and pediatrician dedicated to promoting general health and well-being.
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