Laparoscopy Hiatus Hernia

The diaphragm is a sheet of muscle that separates the lungs from the abdomen. The left half of the diaphragm contains a small hole (hiatus) through which passes the food pipe or esophagus. Normally this hole fits snugly around the esophagus. The J-shaped stomach sits below the diaphragm. Hiatus hernia is a condition in which the upper portion of the stomach protrudes into the chest cavity through the esophageal hiatus.

In some people, the hiatus in the diaphragm weakens and enlarges; it is not known why this occurs. In some patients it may be due to heredity while in others it may be caused by obesity, exercises such as weightlifting, or straining at stool. Whatever the cause, a portion of the stomach herniates, or moves up, into the chest cavity through this enlarged hole producing a hiatus hernia. Hiatus hernias are very common and occur in up to 60% of people by the age of 60.

There are 2 types of hiatus hernia.

• The sliding type: As its name implies, occurs when the junction between the stomach and esophagus slides up through the esophageal hiatus when the pressure in the abdominal cavity increases. When the pressure is relieved, the stomach falls back down with gravity to its normal position.

• The rolling or paraesophageal type: In this type of hernia a portion of the stomach remains stuck in the chest cavity and does not come back to its normal position below the diaphragm.

Hiatus hernias, especially the sliding type, do not produce symptoms in most patients. When symptoms do occur they may only be heartburn and regurgitation as a result of the acid in the stomach refluxing back into the esophagus (gastro-esophageal reflux). Belching, coughing and hiccups may be other symptoms related to hiatus hernia. In some patients longstanding reflux of acid into the esophagus may cause injury to and bleeding from the lining of the esophagus. This causes anaemia or a low red blood cell count. Further, chronic inflammation of the lower esophagus may produce narrowing (stricture) in this area. This, in turn, makes swallowing difficult, and food does not pass easily into the stomach.

At times, a paraesophageal hiatus hernia causes chest or upper abdominal pain when the stomach becomes trapped above the diaphragm through the narrow esophageal hiatus. The patient may get persistent vomiting and become unwell if the blood supply of the trapped stomach is cut off. This becomes a medical emergency.

Although a hiatus hernia can cause chest pain very similar to heart pain do not assume that such pain is caused by the less serious condition of the two. When in doubt, it is safer to be seen by a doctor immediately in order to rule out more problems related to the heart.

Patients who have a sliding hiatus hernia and associated gastroesophageal reflux disease are often advised some lifestyle modifications and medication as the first line of treatment.

Lifestyle modifications

• Avoid foods or substances that increase reflux of acid into the esophagus, such as:

• Nicotine (cigarettes)

• Caffeine or coffee

• Chocolate

• Fatty or oily foods

• Alcohol

• Eat smaller, more frequent meals

• Not to eat within 2-3 hours of bedtime

• Avoid bending, stooping, abdominal exercises or tight belts all of which increase abdominal pressure and cause reflux

• If overweight, lose weight as obesity is likely to increases abdominal pressure

• At nighttime elevate the head end of the bed 8 to 10 inches by putting pillows or a wedge under the upper part of the mattress. Gravity helps keep stomach acid out of the esophagus while sleeping

Drugs

Some patients with severe symptoms may be prescribed drugs to reduce the secretion of stomach acid or to increase the muscle strength of the lower esophagus, thereby reducing acid reflux.