Diaphragmatic (hiatal) hernias: All you need to know

With a diaphragmatic hernia (hiatal hernia), a part of the stomach pushes through the diaphragm into the chest cavity. Often, the condition occurs in connection with heartburn. In many cases a diaphragmatic hernia has no symptoms. In some cases, however, surgery is necessary to avoid serious complications.

How does diaphragmatic hernia develop?

With a diaphragmatic hernia, a part of the stomach pushes through the opening for the esophagus (hiatus esophagus) and enters the chest cavity. Usually, only the upper part of the stomach is affected.

The diaphragm is the most important respiratory muscle. It separates the chest cavity, which contains the lungs and the heart, from the abdominal cavity, which contains organs such as the liver, kidneys, and the gastrointestinal tract.

There are three large openings in the diaphragm. Through one opening, the great vena cava passes into the abdomen. The main artery (aorta) passes through another opening. The esophagus runs to the stomach through the last opening.

If the pressure in the abdominal cavity increases, the opening for the passage of the esophagus may become unstable. The ligaments that hold the esophagus to the opening can also be damaged. As a result, a part of the stomach can enter the thoracic cavity.

What are the risk factors for diaphragmatic hernia?

Age is an important risk factor as most cases occur after the age of 50. Physicians suggest that more than 50 percent of people over the age of 50 have a form of diaphragmatic hernia. Often, the disease remains undetected if no discomfort occurs.

Women are more likely to be affected than men. Other risk factors for the emergence of diaphragmatic hernia are obesity, a low-fiber diet, and pregnancy.

What types of hiatal hernia are there?

Physicians distinguish three forms of diaphragmatic hernia:

• Axial sliding hernia
• Paraesophageal hernia
• Mixed forms

Axial sliding hernia is the most common form of hiatal hernia. This includes about 80 percent of all diaphragmatic hernias. In this form, a piece of stomach slips along the esophagus into the chest cavity. The stomach thus forms a kind of extension of the esophagus.

Paraesophageal hernia occurs less frequently than the axial sliding hernia. In this type of diaphragmatic hernia, part of the stomach also enters the abdominal cavity through the diaphragm. However, the protruding part of the stomach forms a baggy bulge, which rests on the diaphragm next to the esophagus. The esophagus leads directly into the part of the stomach that has not emerged through the diaphragm (“paraesophageal” means “next to the esophagus”).

All other forms of hiatal hernia are referred to as mixed forms. In rare cases, it can happen that the entire stomach passes through the diaphragm and lies in the abdominal cavity.

What are the symptoms of diaphragmatic hernia?

About 60 percent of patients with hiatal hernia have no symptoms. In most cases, these are axial hiatal hernias (when only a small part of the stomach has passed through the diaphragm).

When symptoms occur, they are usually the classic symptoms of gastroesophageal reflux disease. The most common side effect is heartburn: There is pain behind the sternum and difficulty swallowing. The pain behind the sternum usually worsens in a lying position.

Diaphragmatic hernia causes heartburn as the passage of the stomach through the diaphragm causes gastric acid to enter the esophagus. Normally, this prevents constriction in the diaphragm opening.

The less frequent paraesophageal hernia can also cause difficulty swallowing (dysphagia) and a feeling of pressure in the chest. Cardiac discomfort also sometimes occurs when the heart is restricted by the diaphragmatic hernia.

How does the doctor diagnose diaphragmatic hernia?

The patient usually describes typical symptoms such as heartburn, pain behind the sternum, and difficulty when swallowing. This gives the doctor the first indications of the possible presence of diaphragmatic hernia. However, since about two thirds of all diaphragmatic hernias do not cause any symptoms, they are often discovered by accident.

To confirm the presence of a hiatal hernia, the doctor may perform a gastroscopy. This allows the doctor to track the esophagus and examine the location and spread of diaphragmatic hernia.

Alternatively, an examination with X-ray contrast agent can provide information. The patient swallows a fluid that is visible on the x-ray, allowing the doctor to track the location and position of the stomach on the x-ray.

To determine if surgery is required to treat the diaphragmatic hernia, a pressure measurement may be used to check the function of the esophageal occlusion. In addition, the pH within the esophagus can be used to determine if there is a sustained acid load that would require treatment.

How is diaphragmatic hernia treated?

Lighter forms of an axial diaphragmatic hernia often present no symptoms and should not be a cause for concern. If an axial diaphragmatic hernia causes no discomfort and does not lead to a permanently inflamed esophagus, no treatment is necessary. Therapy is advisable only with complaints such as heartburn, pain, or difficulty when swallowing.

An important measure against the complaints is a change in nutrition. Spices and spicy foods can worsen symptoms. Alcohol can also have an adverse effect. Patients should also not smoke and avoid stress as both factors affect the production of stomach acid. Obesity is also a risk factor for the development and aggravation of a diaphragmatic hernia. Weight loss can therefore be useful. An operation should be considered only if these measures do not help.

Paraesophageal or mixed hernias must always be operated on regardless of discomfort because of high risk of complications. They may, for example, result in a blockage of the food pathway, an ulcer, or an entrapment of blood vessels.

What to do if the diaphragmatic treatment does not work?

If lifestyle measures do not improve symptoms, a diaphragmatic hernia can be treated by surgery. The most common surgical procedure is the so-called fundoplication. Here, a part of the stomach is sewn like a cuff around the stomach entrance, creating a new reflux barrier. Leftover food and stomach acid cannot cause discomfort by easily entering the esophagus. In addition, sometimes the stomach is attached by sutures to the diaphragm so it retains its position (gastropexy).

Conclusion

Diaphragmatic hernias are common, but they are often mild and cause no discomfort. When symptoms such as heartburn or pain occur, sufferers can usually be helped by changing dietary habits. If this approach is not successful, surgery may be performed. In cases of some forms of diaphragmatic hernia, surgery is essential to avoid complications.