Hiatal hernia

Hiatal hernia is the movement of the cardia or part of the stomach from the peritoneal cavity to the mediastinum through the 'esophageal hiatus. The hiatus oesophageus is formed by the diaphragm and the gastroesophageal junction enters the mediastinum (sliding hernia - par glissement), the gastric fundus (paraesophageal hernia), or the fundus enters the mediastinum even with the gastroesophageal junction with a preserved His angle ( mixed hernia). An extreme case is the dislocation of the entire stomach into the mediastinum, the so-called upside-down stomach, when the cardia and pylorus remain in the abdominal cavity, the stomach (and other intra-abdominal organs) can be displaced into the mediastinum or pleural cavity even in severe injuries. These are false hernias' (protrusions), the gate of which is a traumatic rupture of the diaphragm.



Division

 * Sliding - the most common, false hernia - is not a hernia sac, the angle of His is missing, the main complication is gastroesophageal reflux.
 * Paraesophageal - rare, hernia sac is formed, gastroesophageal junction remains in peritoneal cavity, angle of His is preserved, complications are venostasis with bleeding, ulceration, necrosis with wall perforation during strangulation, obstruction with disruption passages, oppression of intrathoracic structures (heart, lungs).
 * Mixed - a combination of the previous types.

Clinical symptoms
Clinically, swallowing difficulties, sternal pressure, epigastric pain (during strangulation), vomiting (in passage disorders), heartburn in gastroesophageal reflux in slippery or mixed hernias, and chronic bleeding anemia are present.

Diagnostics
The diagnosis is made using X-ray (swallowing of a contrast agent - will determine the type of hernia), X-ray of the chest (gastric bubble in the mediastinum), endoscopy (evidence of esophagitis - gastroesophageal reflux, otherwise indicated pH-metry).

Therapy
Conservative treatment consists of administration of proton pump inhibitors (omeprazole, e.g. Helicid&reg;) or H2-blockers (ranitidine, e.g. Ranital®, Ranisan®; famotidine, e.g. Quamatel®) for gastroesophageal reflux (slip hernia).

Surgical treatment is indicated for every paraesophageal hernia and for conservatively unmanageable reflux, includes repositioning of the stomach, resection or retention of the hernia sac, closure of the hernia gate (hiatorrhaphy), possibly. fixation of the fundus to the diaphragm (fundopexy - can also be used to close the defect) and fixation of the anterior stomach wall to the abdominal wall (gastropexy), in case of gastroesophageal reflux, fundoplication according to Nissen-Rossetti is indicated.