Atlas of pathophysiology, 2 Edition

Part II - Disorders

Gastrointestinal Disorders

Hiatal Hernia

Hiatal hernia is a defect in the diaphragm that permits a portion of the stomach to pass through the diaphragmatic opening into the chest. Hiatal hernia is the most common problem of the diaphragm affecting the alimentary canal. Treatment can prevent complications such as strangulation of the herniated intrathoracic portion of the stomach.

Age Alert

Hiatal hernias are common, especially in people over age 50.

Causes

·   Esophageal carcinoma

·   Kyphoscoliosis

·   Trauma

·   Congenital diaphragm malformations

Contributing factors

·   Aging, obesity, trauma

Pathophysiology

Hernias typically result when an organ protrudes through an abnormal opening in the muscle wall of the cavity that surrounds it. In hiatal hernias, a portion of the stomach protrudes through the diaphragm.

Three types of hiatal hernia can occur: sliding, paraesophageal (rolling), or mixed, which include features of both. In a sliding hernia, both the stomach and the gastroesophageal junction slip up into the chest, so the gastroesophageal junction is above the diaphragmatic hiatus. In paraesophageal hernia, a part of the greater curvature of the stomach rolls through the diaphragmatic defect.

Hiatal hernia contributes to gastroesophageal reflux disease, which leads to erosion and fistulas between the esophagus and trachea.

Signs and symptoms

·   Heartburn 1 to 4 hours after eating; aggravated by reclining, belching, or conditions that increase intra-abdominal pressure

·   Regurgitation or vomiting

·   Retrosternal or substernal chest pain (typically after meals or at bedtime)

·   Feeling of fullness after eating

·   Feeling of breathlessness or suffocation

·   Chest pain resembling angina pectoris

·   Dysphagia

Diagnostic test results

·   Chest X-ray reveals an air shadow behind the heart in a large hernia; lower lobe infiltrates with aspiration.

·   Barium swallow with fluoroscopy detects a hiatal hernia and diaphragmatic abnormalities.

·   Endoscopy and biopsy results identify the mucosal junction and the edge of the diaphragm indenting the esophagus; differentiate hiatal hernia, varices, and other small gastroesophageal lesions; and rule out malignant tumors.

·   Esophageal motility studies reveal esophageal motor or lower esophageal pressure abnormalities before surgical repair of the hernia.

·   pH studies identify reflux of gastric contents.

·   Acid perfusion (Bernstein) test identifies esophageal reflux.

·   Blood chemistry reveals decreased serum hemoglobin level and hematocrit in patients with paraesophageal hernia, if bleeding from esophageal ulceration is present.

·   Fecal occult blood test reveals presence of blood.

·   Analysis of gastric contents possibly shows the presence of blood.

Treatment

·   Restrict activities that raise intra-abdominal pressure (coughing, straining, bending)

·   Pharmacologic agents: antiemetics, stool softeners, cough suppressants, antacids, and cholinergics

·   Proton pump inhibitors

·   Diet modifications: small, frequent, bland meals; not eating 2 hours prior to lying down; weight-loss programs

·   Avoidance of foods that relax the lower esophageal sphincter, such as caffeine, mint, and chocolate

·   Smoking cessation

·   Surgical repair

P.187

STOMACH HERNIATION

image

image