Hiatus hernia (or hiatal hernia) is a relatively frequent finding that may be asymptomatic or on the contrary causes a number of complications.
Hiatus hernia means a protrusion of upper part of stomach into the chest through a weakened diaphragm. The most common type is a sliding hernia, by which the gastroesophageal junction (border between esophagus and stomach) is elevated above diaphragm. Much less common is a so called paraesophageal hernia that means an elevation of part of stomach above the diaphragm with a normal position of gastroesophageal junction. The last type is the combination of both previous types.
Schema - hiatus hernia (part of the stomach is extended above the diaphragm)
The cause of hernia is often not clear but it is certainly connected to obesity and frequent increase of intra-abdominal pressure (chronic cough, lifting heavy objects, pregnancy, chronic constipation, etc.).
Hiatus hernia has usually no symptoms and is an incidental finding during an upper GI endoscopy (gastroscopy). Sliding hernia affects correct connection of the esophagus and stomach and impairs the function of lower esophageal sphincter causing frequent return of stomach acid back into the esophagus. This condition is called gastroesophageal reflux disease and it is associated with heartburn, chest pain and sometimes dry cough. Esophageal mucosa is constantly irritated by acidic juices and this can lead to a formation of so called Barrett's esophagus. Barrett's esophagus represents a certain risk factor of esophageal cancer development.
Paraesophageal hernia may incarcerate and this situation is followed by severe abdominal pain and possible gastric bleeding.
Endoscopic examination is the best examination method of hiatus hernia. Hernia is diagnosed and its size can be measured. In addition gastroscopy shows us the state of mucous membranes in esophagus and excludes clinical signs of reflux disease. If there is any suspicious finding like suspected mucosa of Barrett’s esophagus, upper GI endoscopy allows us to take a bioptic sample for further evaluation.
Asymptomatic hiatus hernias are not treated. If the association exists with gastroesophageal reflux disease, we use drugs against stomach acidity to protect the lining of the esophagus. A medication should be accompanied by lifestyle measures – alcohol and coffee restriction and total smoking ban. Severe and extensive hiatus hernia that is not responding to pharmacotherapy requires a surgical procedure. Most common is the so-called fundoplication, by which surgeon completely reconstructs the area of lower esophageal sphincter. It is necessary to be careful not to create this area too narrow, or it leads to troubles with swallowing and food accumulation in esophagus.