Hernia Of The Esophageal Opening Of The Diaphragm - Symptoms, Treatment, Surgery

2024 Author: Rachel Wainwright | [email protected]. Last modified: 2023-12-15 07:39

Hernia of the esophageal opening of the diaphragm

The content of the article:

1. Causes and risk factors
2. Forms
3. Stages
4. Symptoms of a hiatal hernia
5. Diagnostics
6. Treatment of hernia of the esophageal diaphragm
7. Possible complications and consequences
8. Forecast
9. Prevention

A hiatal hernia is a protrusion into the chest cavity of the abdominal segment of the esophagus and the adjacent part of the stomach, and sometimes at the same time the intestinal loops, through the enlarged esophageal opening in the diaphragm. In the medical literature, the term "hiatal hernia" is sometimes used for this pathology; in everyday life, simplified names are often used - hernia of the esophagus or diaphragmatic hernia.

The disease occurs in about 5% of the adult population and is characterized by a chronic recurrent course.

Forms and signs of a hiatal hernia

Causes and risk factors

The most common cause of hiatal hernias is congenital or acquired hiatal ligament weakness. In about half of the cases, the disease is diagnosed in patients over 50 years of age due to progressive degenerative-dystrophic changes in the connective tissue. A sedentary lifestyle, exhaustion and an asthenic physique increase the likelihood of illness. The pathological development of connective tissue structures, contributing to the appearance of hernias, can be indicated by concomitant diseases: flat feet, varicose veins, hemorrhoids, Marfan syndrome, etc.

The provoking factor in the formation of a hernia of the esophageal opening is most often a significant increase in intra-abdominal pressure with prolonged tearful cough, flatulence, ascites, neoplasms and severe obesity, as well as with blunt trauma to the abdomen, sharp bends, overwhelming physical labor and simultaneous lifting of a heavy load. In women, the disease is often diagnosed during pregnancy: according to the WHO, hiatus hernias are found in 18% of patients with repeated pregnancy.

Prolonged tearing cough increases intra-abdominal pressure and increases the likelihood of a hiatal hernia

A persistent increase in intra-abdominal pressure is also observed in some diseases of the abdominal organs, accompanied by persistent vomiting and impaired peristalsis. Inflammatory processes in the upper gastrointestinal tract, reflux esophagitis and burns of the mucous membranes lead to cicatricial deformities of the esophagus, which contribute to its longitudinal shortening and weakening of the ligamentous apparatus. For this reason, diaphragmatic hernias are often associated with chronic gastritis and gastroduodenitis, gastric ulcer and 12 duodenal ulcer, cholecystitis, pancreatitis, etc.

In rare cases, the development of a hernia of the esophagus is due to congenital malformations of the upper gastrointestinal tract. The risk group includes patients with a short esophagus and the so-called pectoral stomach (congenital shortening of the esophagus).

Forms

Hiatal hernias are classified into three groups depending on the location and anatomical features.

1. Axial (axial, sliding) - the most common type of hiatal hernias, characterized by free penetration of the abdominal segment of the esophagus, cardia and fundus of the stomach into the chest cavity with the possibility of independent return to the abdominal cavity when the position of the body changes. Taking into account the nature of the dislocation of anatomical structures, cardiac, cardiofundal, subtotal and total gastric subtypes are distinguished among axial hiatal hernias.
2. Paraesophageal - manifested by the displacement of a part of the stomach into the chest cavity with the normal location of the distal segment of the esophagus and cardia. Paraesophageal hernias are differentiated into fundic and antral hernias: in the first case, the fundus of the stomach is located above the diaphragm, in the second - the antrum.
3. Mixed hiatal hernia is a combination of the two previous types.

Types of hernia of the esophageal opening of the diaphragm

Congenital malformations of the gastrointestinal tract, in which there is an intrathoracic position of the stomach due to insufficient length of the esophagus, should be considered as a separate category.

Stages

Based on the degree of displacement of the stomach into the chest cavity, there are three stages of axial diaphragmatic hernias.

1. The abdominal segment is located above the diaphragm, the cardia is at the level of the diaphragm, the stomach is directly adjacent to the cardia.
2. The lower esophagus protrudes into the chest cavity, the stomach is located at the level of the esophageal opening.
3. Most of the subphrenic structures extend into the chest cavity.

Symptoms of a hiatal hernia

In about half of cases, hiatus hernia is asymptomatic and is diagnosed by chance. Clinical manifestations appear as the size of the hernial sac increases and the compensatory capabilities of the sphincter mechanism at the border of the stomach and esophagus are exhausted. As a result, gastroesophageal reflux is observed - the reverse movement of the contents of the stomach and duodenum 12 along the esophagus.

As the hernia of the esophageal diaphragm increases, the patient may develop gastroesophageal reflux disease

With a large hiatus hernia, reflux esophagitis often develops, or gastroesophageal reflux disease - inflammation of the walls of the esophagus caused by constant irritation of the mucous membranes with an acidic environment. The main symptoms of a hiatal hernia are associated with the clinical picture of reflux esophagitis, which is characterized by:

• frequent heartburn and a feeling of bitterness in the mouth;
• hiccups and belching with a sour and bitter aftertaste;
• hoarseness and sore throat;
• thinning of tooth enamel;
• pain in the epigastrium, in the epigastric region and behind the sternum, radiating to the back and interscapular region;
• causeless vomiting without preceding nausea, mainly at night;
• difficulty swallowing, which is especially pronounced when taking liquid food and in a stressful environment;
• dyspeptic disorders.

Progressive reflux esophagitis is accompanied by the development of erosive gastritis and the formation of peptic ulcers of the esophagus, causing latent bleeding in the stomach and lower esophagus, which leads to anemic syndrome. Patients complain of weakness, headaches, fatigue and low blood pressure; cyanosis of mucous membranes and nails is often noticeable.

When the hernial sac is infringed, the painful sensations increase sharply and take a cramping character. At the same time, signs of internal bleeding appear: nausea, vomiting of blood, cyanosis, a sharp drop in blood pressure.

Approximately one third of patients with a hiatal hernia have cardiac complaints - chest pains radiating to the scapula and shoulder, shortness of breath and heart rhythm disturbances (paroxysmal tachycardia or extrasystole). A differential sign of a diaphragmatic hernia in this case is increased pain in the supine position, after eating, sneezing, coughing, bending forward and passing intestinal gases. After a deep breath, belching and a change in posture, the painful sensations, as a rule, subside.

Diagnostics

In the diagnosis of hiatal hernias, instrumental imaging methods play a leading role:

• esophagogastroscopy;
• intraesophageal and intragastric pH-metry;
• esophagomanometry;
• impedance measurement;
• X-ray of the esophagus, stomach and chest organs.

Restrained hiatus hernia on X-ray

Endoscopic examination reveals reliable signs of a hiatus hernia: expansion of the esophageal opening, displacement of the esophageal-gastric line upward and changes in the mucous membranes of the esophagus and stomach, characteristic of chronic esophagitis and gastritis. Esophagogastroscopy is often combined with a pH meter; if severe ulceration and erosion are found, the selection of a biopsy is also shown in order to exclude oncopathology and precancerous conditions.

On X-ray images, signs of axial hernias are clearly visible: high location of the esophagus, protrusion of the cardia over the diaphragm, disappearance of the subphrenic esophagus. With the introduction of a contrast agent, a suspension of suspension is observed in the hernia area.

To assess the state of the upper and lower esophageal sphincters and esophageal motility, esophagomanometry is performed - a functional study using a water-perfusion catheter equipped with a registration sensor. Pressure indicators in the contracted state and at rest allow us to judge the strength, amplitude, speed and duration of contractions of the sphincters and smooth muscles of the esophageal walls.

Impedance measurement allows you to get an idea of the acid-forming, motor-motor and evacuation function of the stomach, based on the electrostatic resistance between the electrodes of the esophageal probe. Impedance measurement is considered the most reliable way of recognizing gastroesophageal reflux with a simultaneous assessment of its type - depending on the pH value, acidic, alkaline or slightly acidic reflux is distinguished.

In case of severe anemic syndrome, fecal occult blood analysis is additionally performed. To exclude cardiovascular pathology in the presence of complaints of a cardiological profile, it may be necessary to consult a cardiologist and conduct gastrocardiomonitoring - a combined daily monitoring of gastric acidity and an ECG according to Holter.

Treatment of hernia of the esophageal diaphragm

With a small hernia, medical tactics are usually limited to pharmacotherapy of gastroesophageal reflux, aimed at stopping inflammation, normalizing pH, restoring normal motility and mucous membranes of the upper gastrointestinal tract. The therapeutic regimen includes proton pump inhibitors and histamine receptor blockers; with increased acidity, antacids are prescribed - aluminum and magnesium hydroxides, magnesium carbonate and oxide.

The patient must follow a sparing daily regimen, refrain from smoking and alcohol, avoid stress and excessive physical exertion. In case of severe pain behind the sternum, it is recommended to give the head of an elevated position.

For the duration of treatment, you should adhere to the diet number 1 according to Pevzner. The regimen of food intake is also important: the daily diet is divided into 5-6 servings; it is important that the last meal in the evening took place at least three hours before bedtime.

Compliance with the Pevzner diet number 1 can reduce the unpleasant symptom of gastroesophageal reflux

With the low efficiency of drug therapy, dysplasia of the mucous membranes of the esophagus and a complicated course of a hiatal hernia, surgery is the best way out. Depending on the size and localization of the hernial sac, the nature of pathological changes in the esophageal wall, the presence of complications and concomitant diseases, various methods of surgical treatment of hiatal hernias are used:

• strengthening of the esophageal-phrenic ligament - suturing of the hernial orifice and hernia repair;
• fundoplication - restoration of an acute angle between the abdominal segment of the esophagus and the fundus of the stomach;
• gastropexy - fixation of the stomach in the abdominal cavity;
• resection of the esophagus is an extreme measure, which is used in case of formation of cicatricial stenosis of the esophagus.

Fundoplication is one of the surgical methods for the treatment of hiatal hernia

Possible complications and consequences

Of the complications of hernia of the esophageal opening of the diaphragm, the greatest threat is aspiration pneumonia, which develops when large volumes of stomach contents enter the respiratory tract. Aspiration pneumonia accounts for almost a quarter of all reported cases of severe lung infection. Frequent irritation of the respiratory tract with small portions of regurgitated gastric contents leads to chronic tracheobronchitis.

Also of concern are complications from the cardiovascular system caused by irritation of the vagus nerve by a large hernia. Against the background of a diaphragmatic hernia, reflex angina pectoris may develop, and with spasm of the coronary vessels, the risk of myocardial infarction increases.

The long-term consequences of a hiatal hernia and the progressive course of reflux esophagitis include:

• the appearance of erosions and peptide ulcers;
• esophageal and gastric bleeding;
• cicatricial stenosis of the esophagus;
• infringement of a hernia;
• perforation of the esophagus.

The long course of gastroesophageal reflux with hernia creates the prerequisites for dysplastic and metaplastic changes in the epithelial tissue of the mucous membranes of the esophagus. An example of metaplasia with a high probability of malignancy is Barrett's esophagus, which is characterized by the replacement of the normal squamous epithelium of the esophageal wall by the columnar epithelium characteristic of the intestine, as well as for the cardiac and fundic parts of the stomach. This creates the prerequisites for the development of a malignant tumor process. Metaplastic goblet cells are especially susceptible to malignancy when the affected area is more than 3 cm.

Forecast

With conservative treatment, hiatal hernias are prone to recurrence, therefore, at the end of the main course of treatment, patients are subject to dispensary registration with a gastroenterologist. After surgery, the likelihood of recurrence is minimal.

Adequate selection of therapeutic regimens and regular prevention of exacerbations of reflux esophagitis can achieve long-term remission and prevent complications. With a small hernia and a good response to drug therapy, there is a chance to achieve a complete recovery. Lack of treatment, on the other hand, provokes complications and increases the degree of cancer risk.

Prevention

The best prevention of hiatal hernia in the absence of clinical signs is the rejection of bad habits, good nutrition and regular exercise. The training program should include specialized exercises to strengthen the abdominal wall.

In order to prevent recurrence of hiatal hernia, it is important to timely identify and treat diseases of the digestive system, ensure the normal functioning of the gastrointestinal tract and limit the consumption of foods that irritate the mucous membranes. The ban includes spicy, fatty, fried and salty foods, rich broths, smoked meats, alcohol, tomatoes, radishes, cabbage, onions, legumes and citrus fruits, as well as whole-grain bread and cereals rich in fiber. Also, do not get carried away with chocolate, delicious hard and moldy cheeses, red meat and cream cakes.

The most favorable products for the restoration of the mucous membranes of the esophagus and stomach are considered fine-grained cereals, white rice, low-fat milk and meat, ripe sweet fruits without skin and seeds, puddings, soft-boiled eggs, steamed omelets and boiled vegetables. The health-improving effect is greatly increased if you adhere to fractional portioned meals and find time for walking after an evening meal.

Patients prone to obesity, it is desirable to bring the weight in line with the physiological norm. With a history of hernial diseases, intense power loads are contraindicated, but exercises in exercise therapy groups have a good effect.

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Anna Kozlova Medical journalist About the author

Education: Rostov State Medical University, specialty "General Medicine".

The information is generalized and provided for informational purposes only. At the first sign of illness, see your doctor. Self-medication is hazardous to health!