the esophagus, the diaphragm, the
hiatus and the hernia
reflux and other effects of
hiatus hernia
making a diagnosis
drug treatment
surgical treatment
diet
drugs used in this condition
when to consult your doctor
further reading
The esophagus, the diaphragm, the hiatus and the hernia
The diaphragm separates
structures in the chest from those in the abdomen. Some
organs are present both in the chest and abdomen, such as
the foodpipe (esophagus) and the artery carrying blood to
the legs (the aorta), and others. These organs make 
their own holes (hiatuses) in the
diaphragm.
The esophagus passes through the esophageal hiatus to
enter the abdomen and join the stomach. The stomach is
loosely hanging in the abdominal cavity, and sometimes
slides through the esophageal hiatus to partly enter the
chest. This condition is a hiatus hernia, and is a way of
saying that the stomach has herniated through the hiatus
from the abdomen into the chest.
reflux and other effects of hiatus hernia
A small part of the stomach entering the chest would not mean a great deal by itself. However, one of the important functions of the muscle at the lower end of the esophagus (the "cardiac sphincter", also called the lower esophageal sphincter) is to prevent acid in the stomach from refluxing into the esophagus, which, unlike the stomach, is not designed to tolerate acid. If a hiatus hernia is present, the function of the muscle is often weakened. Acid begins to reflux into the esophagus, and may produce the gastroesophageal reflux disease (GERD).
When acid enters the esophagus, the patient feels the symptoms of sour eructations. There may be a burning sensation in the middle of the chest or in the upper abdomen. (Symptoms of reflux can be confused with those of peptic ulcer or even a heart attack!) In more severe cases the acid reaches the throat and enters the windpipe, and from there into the lungs. This can result in recurrent chest infections and asthma. In fact, in asthmatics who are not responding to treatment, it is important to rule out acid reflux. Acid in the esophagus can cause esophageal ulcers. These ulcers may heal with scarring, causing the esophagus to narrow and the patient to experience difficulty in swallowing. It should be stressed that not all patients with hiatus hernia have these symptoms, and for that matter, not all patients with these symptoms have a hiatus hernia.
Symptomatic patients can be diagnosed by gastroscopy or by a barium swallow. Of the two, endoscopy is the preferred investigation, because of its greater accuracy and its ability to pick up other lesions. Most patient will not need further tests, unless the diagnosis is in doubt.
drug treatment
Hiatus hernias are treated by medicines. The patient is advised to sleep with the upper body elevated at an angle of 30o. this can be done by means of pillows or by bricks placed under the head end of the bed. Reflux is minimized by frequent small, bland meals. Since acid plays an important role in the symptoms of hiatus hernia, acid reducing measures are required. These include drugs such as omeprazole, ranitidine and metoclopramide.
A small number of patients do not
respond to drug treatment, and have persistent symptoms,
recurrent chest infection, recurrent episodes of
bronchospasm, or local complications such as ulceration
or stricture formation. Sometimes the normal mucosa of
the lower esophagus is replaced by mucosa resembling that
found in the intestines. This condition is called
Barrett's esophagus, and needs close observation because
of the possibility of the development of cancer. In all
such patients surgical measu
res to
prevent reflux must be considered. At operation the upper
stomach is wrapped around the lower esophagus in a manner
that prevents reflux. The operation, called
fundoplication, has a success rate of over 80%, although
some patients experience a slight difficulty in
swallowing.
These days a laparoscopic approach has been standardized for antireflux surgery, and many believe it to be the method of choice. After surgery the esophagus may become narrow to an extent that it interferes with swallowing. Presently this complication is commoner after laparoscopic repair, but with time laparoscopic results should match and even better the results of open surgery.
Hiatus hernias have the twin problems of acidity and reflux. Acidity can be prevented by avoiding chillies, minimizing alcohol, and above all by avoiding smoking completely.
Reflux can be minimized by keeping the volume of food low. This means that the patient should take small, frequent meals, avoiding drinking too much water.
Drugs to
prevent ulcers in the stomach: omeprazole or
lanzoprazole, ranitidine
Antacids:
digene, gelusil etc may help some patients
Drugs
to prevent vomiting: cisapride, metoclopramide
Small amounts of heartburn and acidity can be controlled by antacids. Most patients will need drugs that block production of acid. These are best prescribed by a doctor. Patients over the age of 40 MUST visit a doctor, not so much for the hiatus hernia, as much as to rule out other conditions.
http://www.nevdgp.org.au/ginf2/murtagh/general/hiatushernia.htm:
a nice site for hiatus hernia
http://www.bdf.org.uk/leaflets/hrtburn.html:
heartburn faqs
Dr Suneet
Sood, MBBS (AIIMS), MS (AIIMS), MAMS, is a
practising surgeon attached to Dharamshila Cancer
Hospital, Sir Ganga Ram Hospital and to Noida Medicare
Center. Formerly Professor of Surgery, Himalayan
Institute of Medical Sciences, Dehradun, Dr Sood has a
special interest in gastrointestinal surgery. He has had
an active academic career, has published several papers
in national and international journals, and is the Editor
(with Dr Anurag Krishna) of a widely acclaimed book
titled Surgical Diseases in Tropical Countries.
Contact
Nos: 2486788, 9811052966, suneetsood@vsnl.com
Dr Suneet Sood,MS, MAMS,
Editor in chief
Dr
Anurag Krishna, MS, MCh, MAMS
Last revised: May 12, 2000