Hernia Types, Symptoms and Treatment Notes

Hiatus Hernia

Hiatus Hernia Definition: Abnormal protrusion of abdominal viscus through the oesophageal hiatus into the chest.

Hiatus Hernia Types

1. Sliding hernia or oesophagogastric hernia: It is the commonest type of hiatus hernia, accounting for about 80% of cases. It may be associated with GORD.
2. Rolling or para esophageal hernia
3. Mixed hernia
4. Massive herniation.

Read And Learn More: Gastrointestinal Surgery Notes

1. Type 1 hernias are sliding hiatal hernias, where the gastroesophageal junction migrates above the diaphragm. The stomach remains in its usual longitudinal alignment and the fundus remains below the gastroesophageal junction.

2. Type 2 hernias are pure paraoesophageal hernias (PEH); the gastroesophageal junction remains in its normal anatomic position but a portion of the fundus herniates through the diaphragmatic hiatus adjacent to the esophagus, through a defect in the phrenooeso- phageal membrane.

3. Type 3 hernias are a combination of Types 1 and 2, with both the gastroesophageal junction and the fundus herniating through the hiatus. The fundus lies above the gastroesophageal junction.

4. Type 4 hiatal hernias are characterized by the presence of a structure other than stomach, such as the omentum, colon or small bowel within the hernia sac.

Hiatus Hernia Common Symptoms

1. Symptoms due to reflux: Regurgitation and heart burn are the two most common symptoms.
2. Symptoms due to complications: They are dysphagia, odynophagia, haematemesis and melaena.
3. Nonoesophageal symptoms: They are asthma and chest pain.

Sliding Herina

Sliding Herina: In this variety, the squamocolumnar junction or Z line is at a higher place resulting in loss of angle of His. Due to loss of angle of His and lower oesophageal sphincter activity, reflux takes place. Over a period of time, it changes into columnar-lined oesophagus (CLO).

Anatomical factors which prevent sliding hernia

• Presence of 2 cm of intra-abdominal oesophagus.
• The angle of His: The oesophagocardiac angle of about 45° has valvular effect.
• Mucosal folds at the oesophagocardiac junction.
• Positive intra-abdominal pressure which closes the abdominal oesophagus.
• Lower oesophageal sphincter (LOS): It is a functional sphincter which increases the pressure during coughing, straining, etc.

Causes Of Sliding Hernia

• Deposition of fatty tissue in the hiatus leads to weakening of the hiatus in obese individuals.
• Advancing age resulting in muscular degeneration can predispose to hernia.
• Raised intra-abdominal pressure due to lower abdominal tumours, pregnancy, etc.
• Saint’s triad: Gallstones, diverticulosis and hiatus hernia can occur together in a patient.

Sliding Hernia Clinical Features

• In many patients, there may not be any symptoms. Symptoms are like that of reflux oesophagitis—heart¬burn, chest pain, bloating sensation.
• More common in women, especially if obese.
• Symptoms are exaggerated after a heavy meal or binges of alcohol.

Sliding Hernia Investigations

• Oesophagoscopy reveals varying degree of inflammation. During oesophagoscopy, when the patient is asked to strain (Valsalva’s manoeuvre), the sphincter is seen to be more patulous and herniation of gastric mucosal folds can be seen. Reflux of the gastric acid is the most valuable sign. Biopsy should be taken from suspicious areas of metaplasia.
• Barium meal demonstrates gastroesophageal reflux in the Trendelenburg position.
• Ultrasound of abdomen to rule out gallstones. Reflux can be due to some extraluminal pathology compressing GE junction such as retroperitoneal or pancreatic tumours.

Sliding Hernia Treatment

Conservative Treatment: In all cases of GORD, conservative treatment has to be tried first. The results of surgery are appreciated only when the symptoms are significant and conservative treatment fails.

Principles—You can remember the pneumonic LORD

1. Lifestyle changes
   • Decrease in weight
   • Diet control with increased intake of proteins and decreased consumption of fat and sugar.
   • Decreased alcohol and tobacco consumption.
2. Oesophageal mucosa protection
   • Antacids: Preparations containing alginates, cytoprotective agents.
   • H₂ blockers: Ranitidine.
   • Proton pump inhibitors: Omeprazole or esomeprazole.
3. Reflux prevention
   • Oesophageal reflux: Cisapride, metoclopramide
   • Gastric reflux: Domperidone, metoclopramide
4. The decision of surgery: When all measures fail, surgery should be done—reduction of hernial sac, repair of hiatus and reduce reflux by fundoplication— laparoscopic fundoplication

Rolling Hernia

Rolling Hernia: This is also called as paraoesophageal hernia. A Paraoesophageal hernia is characterized by an ascend of the gastric fundus through a defect in the phreno- esophageal membrane. In this condition, cardio- oesophageal junction is normal. Thus, there are no features of reflux oesophagitis but the sac containing stomach in the thorax causes compression of the heart and lung. Volvulus of the stomach is a dangerous complication in this variety.

• It is an uncommon type of hiatal hernia that mainly affects older adults, with a median age of presentation between 65 and 75 years. Loss of elastic fibres as in advancing age or raised increased intra-abdominal pressure or multipara are the few causes mentioned.
• As the hernia enlarges, the greater curvature of the stomach rolls up into the thorax. Because the stomach is fixed at the GE junction, the herniated stomach tends to rotate around its longitudinal axis, resulting in an organoaxial volvulus. Infrequently, rotation occurs around the transverse axis resulting in a mesenteroaxial volvulus.

Rolling Hernia Clinical Features

• No retrosternal burning pain because no reflux
• Discomfort after a small meal
• Feeling of fullness after a meal or dysphagia due to large sac
• Palpitations due to compression on the heart
• Respiratory tract infection and hiccough due to irritation of phrenic nerve.

Rolling Hernia Investigation

• Barium meal shows the sac in the thorax containing stomach. Sometimes, it can be upside down.
• Contrast CT scan is the investigation of choice. Patients who come with features of volvulus with obstruction are evaluated with plain X-ray and CT scan as shown in Fig. 40.12—grossly dilated stomach and duodenum showing a large gas fluid level on the right side with partial volvulus.

Rolling Hernia Treatment: Reduction of the sac and repair of the hiatus by using nonabsorbable suture material to approximate the right crus of the diaphragm. When the defect is large nonabsorbable mesh, such as prolene, is used to cover the defect.

Mixed Hernia

Mixed Hernia: In this, both sliding and rolling hernias are present. Symptoms are mixed—features of reflux esophagitis and compression on the mediastinal structures. Treatment is also mixed and is done for both sliding and rolling hernias.

Mixed Hernia Complications of GORD

1. Stricture oesophagus: It is seen in middle-aged and elderly patients. Due to repeated reflux, ulcers, fibrosis and stricture develop in the lower end of the oesophagus. Early diagnosis by endoscopy followed by frequent dilatation and proton pump inhibitors will help the situation. Peptic strictures are difficult to manage surgically. Surgery is indicated in refractory cases of dilatation, in the form of gastroplasty.
2. Oesophageal shortening is also treated by Collis gastroplasty by using stomach (short oesophagus).
3. Barrett’s oesophagus: Also known as columnar-lined oesophagus (CLO).
4. Gastric/oesophageal ulcers—can give rise to bleeding. Cameron ulcers are the ulcers in the stomach of a patient with haitus hernia. They are seen in about 3 to 5% of the patients. These ulcers occur at the site of extrinsic compression of the diaphragm on the stomach in patients with large hiatal hernias. It can be easily missed. Cameron ulcer is one of the causes of occult upper GI tract bleeding.
5. Aspiration pneumonitis, asthma and pneumonia are common features. Chronic aspiration can result in fibrosis of lung and bronchiectasis.