Case sharing: Wang Danyang, who is over 60 years old, developed heartburn and acid reflux 3 years ago, sometimes accompanied by difficulty in swallowing and vomiting acid after eating, and went to the local hospital and thought it was gastroesophageal reflux. This year, Wang Danyang felt that her symptoms had worsened, so she came to the city hospital for further examination and had a gastrointestinal imaging to find that Wang Danyang had a disease called esophageal hiatal hernia. What is esophageal hiatal hernia? The esophagus passes through the esophageal hiatus in the diaphragm and enters the abdominal cavity to connect with the stomach. Under normal conditions, the esophageal foramen is just large enough to accommodate the passage of the esophagus. When the pressure in our abdominal cavity is greater than that in the thoracic cavity, the pressure difference can “suck” a small part of the stomach into the thoracic cavity, which is called an esophageal hernia. What are the signs of esophageal hiatus hernia? With the exception of some congenital cases, most esophageal hiatus hernia is seen in middle-aged and older patients. Smaller cases of hiatal hernia may be asymptomatic in the early stages, or may only have mild discomfort such as fullness and chest tightness after eating, which may resolve on their own. Patients with esophageal hiatal hernia may be asymptomatic or mildly symptomatic, and the severity of their symptoms is not related to the size of the hernia sac or the severity of esophageal inflammation. In brief, the symptoms of patients with esophageal hiatus hernia are summarized in the following three aspects: 1. In severe cases, esophageal reflux into the trachea can lead to asthma and aspiration pneumonia. With the prolongation of the disease, the hernia will gradually increase in size and cause more obvious gastroesophageal reflux manifestations. At this time, the stomach of patients with esophageal hiatus hernia is like a vinegar bottle without a cap, and the stomach acid will overflow when shaken, which will easily reflux into the esophageal cavity and cause various symptoms of esophageal reflux. (2) Complication-related symptoms (1) bleeding: hiatal hernia can sometimes bleed, mainly due to esophagitis and hernia sacculitis, mostly chronic small amount of oozing blood, which can lead to anemia; (2) reflux esophageal stricture: in a few patients with reflux symptoms, organic stricture occurs, resulting in symptoms such as dysphagia, painful swallowing and vomiting after eating; (3) hernia sac impaction: usually seen in paraesophageal hernia. Patients with hiatal hernia who have sudden severe epigastric pain with vomiting, complete inability to swallow or simultaneous hemorrhage suggest acute intussusception. When the hernia sac is large and compresses the heart, lungs and mediastinum, it can produce symptoms such as shortness of breath, palpitation, cough and cyanosis. When it compresses the esophagus, it may feel like there is esophageal stagnation or difficulty in swallowing behind the sternum. How is it diagnosed? It is difficult to diagnose because it is less common than general “gastroesophageal reflux” and has no specific symptoms and signs. It should be considered in patients with gastroesophageal reflux symptoms, repeated treatment, older age, obesity, and in patients with symptoms clearly related to body position. In addition to symptoms and physical examination, gastroscopy and upper gastrointestinal tract imaging are the conventional means of diagnosing esophageal hiatal hernia, of which X-ray is still the main method for diagnosing esophageal hiatal hernia. Barium X-ray examination: The most commonly used method is to lay the patient on the left side with the head low, and when the stomach is filled with barium, press the abdomen with the hand to make the patient exclude the air by force, and then the indication of hiatal hernia can appear. Gastroscopy: Gastroscopy is second only to radiological examination for the diagnosis of hiatal hernia: in case of hiatal hernia, the lower esophageal sphincter is seen to be relaxed and open during expiration and inspiration, and under normal circumstances the esophagogastric junction point drops during inspiration, but does not change position if there is a hernia. In combination with reflux esophagitis, the number of erythema and ulcers can be observed by gastroscopy. What are the risks of esophageal hiatus hernia? When the presence of esophageal hiatal hernia is neglected, often the patient’s symptoms cannot be relieved or the amount of medication taken cannot be reduced, which increases the burden on the patient and society; when type II and III hernias become embedded, it can lead to necrosis of the hernia contents, causing serious results such as bleeding or gastrointestinal perforation; repeated esophageal reflux and acid stimulation have increased the incidence of esophageal cancer. How to treat esophageal hiatal hernia? A：Medical treatment 1.Changing life habits: reduce fat intake, avoid large pieces of food, reduce foods that stimulate acid secretion and reflux such as alcohol, caffeinated drinks, chocolate, onion, spicy food, mint, etc.; quit smoking; lose weight; avoid sleeping within three hours after eating, move more after eating; elevate the head of the bed when sleeping; reduce work pressure. 2.Take acid-control drugs: Most patients can reduce or control reflux symptoms with acid-control drugs. 3.Take gastric power medicine: morpholine can be added to enhance esophageal and gastric power to solve the symptoms. B: Surgical treatment: If conservative treatment is ineffective, surgical treatment is required. For patients with type II and III hernia and type I esophageal hiatal hernia with more severe symptoms, as well as patients with esophageal ulcer, esophageal stricture, Barrett’s esophagus, esophageal function tests confirming the presence of more severe gastroesophageal reflux, severe bleeding and aspiration pneumonia, surgical treatment should be actively taken. At present, our recommended method is laparoscopic esophageal hiatal hernia repair + fundoplication. Foreign studies have shown that: 1. hiatal hernia is closely related to atypical hyperplasia and even cancer of Barrett’s esophagus and esophagus, and the incidence of these conditions is significantly higher in patients with hiatal hernia; 2. hiatal hernia severely damages the anti-reflux barrier of esophagus, causing obvious symptoms of acid reflux and not easy to control; 3. hiatal hernia affects the contouring function of esophagus, and food and refluxed gastric acid accumulate in the hernia cavity, which aggravates the symptoms. Therefore, patients with severe symptoms and ineffective medical treatment need surgery, and the only way to treat these patients is to repair the esophageal hiatus, restore its normal size and reconstruct the anti-reflux barrier.