Hiatal hernia

Hiatal hernia is the transfer of the cardia or part of the stomach from the peritoneal cavity to the mediastinum by an oesophagal hiatus. The hernia is formed by the hiatus oesophagus of the diaphragm and the gastroesophageal junction (sliding hernia - par glissement), gastric fundus (paraesophageal hernia) enters the mediastinum, or the fundus and gastroesophageal junction enter the mediastinum at the preserved angle of His (mixed hernia). An extreme case is the dislocation of the entire stomach into the mediastinum, the so-called upside-down stomach, when cardia and pylorus remain in the abdominal cavity, the stomach (and other intra-abdominal organs) can dislocate into the mediastinum or pleural cavity even in severe injuries. These are false hernias (projections), the goal of which is a traumatic rupture of the diaphragm.

Division of Hiatal Hernias

 * Sliding - the most common, false hernia - there is no hernia sac, angle of His is missing, the main complication is gastroesophageal reflux.
 * Paraesophageal - rare, hernia sac is present, gastroesophageal junction remains in the peritoneal cavity, angle of His is preserved, complications are usually venostasis with bleeding, ulceration, necrosis with vessel-wall perforation during strangulation, obstruction with passage disorders, 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.

Diagnosis
Diagnosis is made by X-RAY (contrast substance swallowing - determines the type of hernia), chest X-RAY (gastric bubble in the mediastinum), endoscopy (proof of oesophagitis - gastroesophageal reflux, otherwise indicated pH-metre).

Treatment
Conservative treatment involves getting proton pump inhibitors (omeprazole, eg Helicid®) or H2-blockers (ranitidine, eg Ranital®, Ranisan®; famotidine, eg Quamatel®) for gastroesophageal reflux (sliding hernia).

Surgical treatment is indicated for each paraesophageal hernia and for conservatively uncontrollable reflux, it includes gastric reduction, resection or retention of the hernia sac, hernia closure (hiatorafia), or fixation of the fundus to the diaphragm (fundopexy - can also be used to close the defect) and fixation of the anterior gastric wall to the abdominal wall (gastropexy), with gastroesophageal reflux fundoplication according to Nissen-Rossetti is indicated.