Hiatal Hernia

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Hiatus hernia- Protrusion of the stomach through the esophageal hiatus above the diaphragm.

Causes and Incidence The cause is unknown but is thought to be related to congenital weakness or abnormalities that often are hereditary or are due to the aging process, obesity, pregnancy, ascites, low-residue diets, and trauma. Hiatal hernias are common and occur in about 30% of the population. They are more common in women and the elderly.

Disease Process Loss of muscle tone around the diaphragmatic opening predisposes a person to hernia development. There are two types, sliding and rolling. The sliding type, the more common, occurs when the cardioesophageal junction and a fundic portion of the stomach are above the diaphragm, creating a weakened lower esophageal sphincter and gastroesophageal reflux. Rolling hernias involve herniation of the cardia of the stomach above the diaphragm, with possible hemorrhage, obstruction, and strangulation.

Symptoms

Sliding type
Asymptomatic or associated gastroesophageal reflux (GER) and heartburn; possible hemorrhage

Rolling type
Asymptomatic unless hemorrhage or strangulation occurs, which may cause chest pain and other manifestations imitating myocardial infarction

Potential Complications Esophageal laceration, perforation, or rupture with massive hemorrhage and strangulation with gangrene are the most common complications.

Diagnostic Tests X-ray examination or esophagography is used to visualize the hernia. A Bernstein test is performed to distinguish cardiac from esophageal chest pain (a positive test result indicates esophageal pain). Cardiac conditions (i.e., acute myocardial infarction) must be ruled out if the person has acute symptoms such as chest pain.

Treatments

Surgery
Reduction of rolling hernia to prevent strangulation; fundoplication for complete mechanical incompetence of sphincter or persistent, untreatable symptoms.

Drugs
GER is treated with antacids, antisecretory drugs, and gastrokinetics.

General
Treatment of GER (see Therapeutic Management under Gastrointestinal Reflux Disease).

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