Esophageal hiatal hernia is a disease caused by the passage of intra-abdominal organs (mainly the stomach) into the thoracic cavity through the diaphragmatic esophageal hiatus. Esophageal hiatal hernia is the most common of diaphragmatic hernias, reaching more than 90%, and is a gastroenterological condition. Patients with esophageal hiatal hernia can be asymptomatic or mildly symptomatic, and the severity of their symptoms is independent of the size of the hernia sac and the severity of esophageal inflammation. Hiatus hernia and reflux esophagitis can coexist or exist separately. The disease can occur at any age, but the onset of symptoms increases with age. The prevalence of this disease in the general population census is 0.52%. The disease is more common in women than in men, 1.5 to 3:1.
I. Etiology
1. Congenital factors of esophageal dysplasia.
2, structure of the esophageal cleft site, such as muscle with atrophy or muscle tone weakening.
3. Acquired factors of long-term increased abdominal pressure, such as pregnancy, pneumoperitoneum, chronic cough, habitual constipation, etc. can cause the body of the stomach to herniate above the diaphragm and form an esophageal hiatal hernia.
4. Post-surgical hiatal hernia, such as surgery on the upper part of the stomach or the cardia, which destroys the normal structure can also cause hernia.
5. Traumatic hiatal hernia.
Clinical manifestations
1. Gastroesophageal reflux symptoms
The symptoms include burning sensation behind the sternum or under the glabella, regurgitation of gastric contents, epigastric fullness, belching, and pain. The nature of the pain is mostly burning or pins-and-needles pain, which can be radiated to the back, shoulders, neck and other places. The symptoms may be triggered and aggravated by lying down, eating sweet and acidic foods. This symptom is especially common in sliding hiatal hernia.
2. Complications
(1) Bleeding A hiatal hernia can sometimes bleed, mainly due to esophagitis and herniorrhaphy, mostly due to chronic small amount of blood leakage, which can lead to anemia. Ulceration of the herniated stomach and intestine may lead to vomiting of blood and black stool.
(2) Reflux esophageal strictures In patients with reflux symptoms, organic strictures occur in a few cases, resulting in dysphagia, painful swallowing, and vomiting after eating.
(3) Hernia sac impaction is usually seen in paraesophageal hernia. If a patient with hiatal hernia has sudden severe epigastric pain with vomiting, complete inability to swallow or simultaneous hemorrhage, it suggests acute intussusception.
3.Hernia sac compression symptoms
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 compressing the esophagus, it can feel food stagnation or difficulty in swallowing behind the sternum.
III. Examination
1.X-ray examination
It is still the main method to diagnose esophageal hiatal hernia. For reversible hiatal hernia (especially for mild cases), a negative examination cannot exclude the disease, and those who are highly suspicious clinically should repeat the examination and take special positions, such as supine head-low-foot-high position, whose barium meal imaging can show direct signs and indirect signs.
2.Endoscopy
The diagnostic rate of endoscopy for esophageal hiatal hernia is higher than before, and it can be supplemented with X-ray examination to assist the diagnosis.
3.Esophageal manometry
In the case of esophageal hiatal hernia, esophageal manometry can have abnormal patterns, which can assist in the diagnosis.
IV. Diagnosis
Since this disease is relatively rare and there are no specific symptoms and signs, it is difficult to diagnose. It should be taken seriously in suspected patients with GERD symptoms, older age, obesity, and obvious correlation between symptoms and body position, and some instrumentation is needed to confirm the diagnosis.
V. Treatment
1.Medical treatment
It is suitable for small slip hernia and those with mild reflux symptoms. The principles of treatment are to eliminate the factors of hernia formation, control gastroesophageal reflux, promote esophageal emptying and moderate or reduce gastric acid secretion.
(1) Lifestyle changes
Avoid coffee, chocolate, alcohol, etc. Avoid lying down after meals and eating before sleep.
(2) Take a head-high, foot-low position during sleep and elevate the head of the bed when lying down.
③Avoid bending, wearing tight clothes, vomiting and other factors that increase intra-abdominal pressure.
④Obese people should try to reduce their weight, and those with chronic cough and long-term constipation should try to treat them. For asymptomatic esophageal hiatal hernia and small hiatal hernia, the above treatment can be given appropriately.
(2) Drug treatment For those who already have gastroesophageal reflux symptoms such as chest pain, retrosternal burning, acid reflux or postprandial regurgitation, in addition to the above preventive measures, anti-reflux and protective drugs for esophageal mucosa and prokinetic drugs should be given.
2.Surgical treatment
(1)Indications for surgery
①Esophageal hiatal hernia combined with reflux esophagitis, the effect of medical treatment is not good.
②Esophageal hiatal hernia with pyloric obstruction and duodenal stasis.
③Para-esophageal hiatal hernia and giant hiatal hernia.
(iv) Esophageal hiatal hernia with suspected cancer.
(2) Surgical principles
①Reset the contents of the hernia.
②Repair the loose and weak esophageal hiatus.
③Prevent and control gastroesophageal reflux.
④Keep the gastric outflow tract unobstructed.
⑤Treat coexisting complications.
(3) Surgical methods There are many surgical methods to treat esophageal hiatal hernia, mainly hernia repair and anti-reflux surgery.
VI. Prevention
Prevention of factors that increase the abdominal pressure for a long time, such as pneumoperitoneum, chronic cough and habitual constipation, can reduce the occurrence of esophageal hiatal hernia.