Is a protrusion of part of the stomach through the hiatus of the diaphragm and into the thoracic cavity.

Two types of hiatal hernias:

Sliding hernia the upper stomach and gastroesophageal junction move upward into the chest and slide in and out of the thorax (most common). Paraesophageal hernia or rolling hernia, part of the greater curvature of the stomach rolls through the

diaphragmatic defect next to the gastroesophageal junction. Hiatal hernia results from muscle weakening caused by aging or other conditions such as esophageal carcinoma, trauma, or after certain surgical procedures. Treatment can prevent incarceration of the involved portion of the stomach in the thorax, which constricts gastric

blood supply. Assessment 1. 2. 3. Maybe asymptomatic. Patient may report feeling of fullness or chest pain resembling angina. Sliding hernia may cause dysphagia, heartburn (with or without regurgitation of gastric contents into the mouth), or restrosternal or substernal chest pain from gastric reflux.

4. Severe pain or shock may result from incarceration of stomach in thoracic cavity with paraesophageal hernia. Diagnostic Evaluation 1. Upper gastric intestinal series with barium contrast shows outline of hernia in esophagus. 2. Endoscopy visualizes defect and rules out other disorders, such as tumors or esophagitis. Therapeutic Intervention 1. Elevate head of the bed 6 to 8 inches (15 to 20) to reduce nighttime reflux. Pharmacologic Interventions 1. 2. Antacids neutralize gastric acid and reduce pain. If patient has esophagitis, give histamine-2 receptor antagonist (such as cimetidine or ranitidine) or proton pump inhibitor (such as omeprazole) to decrease acid secretion. Surgical Interventions

1. Gastropexy to fix the stomach in position is indicated if symptoms are severe. Nursing Interventions 1. Advise the patient about preventing reflux of gastric contents into esophagus by:

2. 3.

Eating smaller meals to reduce stomach bulk. Avoiding stimulation of gastric secretions by omitting caffeine and alcohol, which may intensify symptoms. Refraining from smoking, which stimulates gastric acid secretions. Avoiding fatty foods, which promote reflux and delay gastric emptying. Refraining from lying down for at least 1 hour after meals. Losing weight, if obese.

Avoiding bending from the waist or wearing tight-fitting clothes. Advise the patient to report health care facility immediately at onset of acute chest pain may indicate incarceration of paraesophageal hernia. Reassure patient that he or she is not having a heart attack, but all instances of chest pain should be taken seriously and reported to the patients health care provider.

What is a hiatal hernia?

A hiatal hernia is an anatomical abnormality in which part of the stomach protrudes through the diaphragm and up into the chest. Although hiatal hernias are present in approximately 15% of the population, they are associated with symptoms in only a minority of those afflicted. Normally, the esophagus or food tube passes down through the chest, crosses the diaphragm, and enters the abdomen through a hole in the diaphragm called the esophageal hiatus. Just below the diaphragm, the esophagus joins the stomach. In individuals with hiatal hernias, the opening of the esophageal hiatus (hiatal opening) is larger than normal, and a portion of the upper stomach slips up or passes (herniates) through the hiatus and into the chest. Although hiatal hernias are occasionally seen in infants where they probably have been present from birth, most hiatal hernias in adults are believed to have developed over many years.

What causes a hiatal hernia?

It is thought that hiatal hernias are caused by a larger-than-normal esophageal hiatus, the opening in the diaphragm through which the esophagus passes from the chest into the abdomen; as a result of the large opening, part of the stomach "slips" into the chest. Other potentially contributing factors include: 1. A permanent shortening of the esophagus (perhaps caused by inflammation and scarring from the reflux or regurgitation of stomach acid) which pulls the stomach up. 2. An abnormally loose attachment of the esophagus to the diaphragm which allows the esophagus and stomach to slip upwards.

Hiatal Hernia and Exercise

Medical Author: Dr. Jay W. Marks Medical Editor Dr. Dennis Lee A Viewer Asks: I am wondering if exercise will help with a hiatal hernia? Dr. Marks Answers:Exercise has no effect on hiatal hernias. Exercise, however, can increaseacid reflux in people who are prone to acid reflux, presumably those individuals with weak lower esophageal sphincter

muscles. (Exercise increases intra-abdominal pressure and can force stomach acid back into the esophagus through a weak lower esophageal sphincter.) Read more about exercise, drugs, and hiatal hernias

TOP SEARCHED HIATAL HERNIA TERMS: symptoms, treatment, surgery, diet, sliding, acid reflux, esophagus, paraesophageal, shortness of breath

Are there different types of hiatal hernias?

Hiatal hernias are categorized as being either sliding or para-esophageal. Sliding hiatal hernias Sliding hiatal hernias, the most common type of hernia, are those in which the junction of the esophagus and stomach, referred to as the gastro-esophageal junction, and part of the stomach protrude into the chest. The junction may reside permanently in the chest, but often it juts into the chest only during a swallow. This occurs because with each swallow the muscle of the esophagus contracts causing the esophagus to shorten and to pull up the stomach. When the swallow is finished, the herniated part of the stomach falls back into the abdomen. Para-esophageal hernias are hernias in which the gastro-esophageal junction stays where it belongs (attached at the level of the diaphragm), but part of the stomach passes or bulges into the chest beside the esophagus. The para- esophageal hernias themselves remain in the chest at all times and are not affected by swallows. Para-esophageal hiatal hernias A para-esophageal hiatal hernia that is large, particularly if it compresses the adjacent esophagus, may impede the passage of food into the stomach and cause food to stick in the esophagus after it is swallowed. Ulcers also may form in the herniated stomach due to the trauma caused by food that is stuck or acid from the stomach. Fortunately, large para-esophageal hernias are uncommon.

What are the symptoms of hiatal hernia?

The vast majority of hiatal hernias are of the sliding type, and most of them are not associated with symptoms. The larger the hernia, the more likely it is to cause symptoms. When sliding hiatal hernias produce symptoms, they almost always are those of gastroesophageal reflux disease(GERD) or its complications. This occurs because the formation of the hernia often interferes with the barrier (lower esophageal sphincter) which prevents acid from refluxing from the stomach into the esophagus. Additionally, it is known that patients with GERD are much more likely to have a hiatal hernia than individuals not afflicted by GERD. Thus, it is clear that hiatal hernias contribute to GERD. However, it is not clear if hiatal hernias alone can result in GERD. Since GERD may occur in the absence of a hiatal hernia, factors other than the presence of a hernia can cause GERD. Symptoms of uncomplicated GERD include:

heartburn regurgitation

nausea

How does a hiatal hernia cause GERD?

Normally, there are several mechanisms to prevent acid from flowing backwards (refluxing) up into the esophagus. One mechanism involves a band of esophageal muscle where the esophagus joins the stomach called the lower esophageal sphincter that remains contracted most of the time to prevent acid from refluxing or regurgitating. The sphincter only relaxes when food is swallowed, allowing food to pass from the esophagus and into the stomach. The sphincter normally is attached firmly to the diaphragm in the hiatus, and the muscle of the diaphragm wraps around the sphincter. The muscle that wraps around the sphincter augments the pressure of the contracted sphincter to further prevent reflux of acid. Another mechanism that prevents reflux is the valve-like tissue at the junction of the esophagus and stomach just below the sphincter. The esophagus normally enters the stomach tangentially so that there is a sharp angle between the esophagus and stomach. The thin piece of tissue in this angle, composed of esophageal and stomach wall, forms a valve that can close off the opening to the esophagus when pressure increases in the stomach, for example, during strenuous exercise. When a hiatal hernia is present, two changes occur. First, the sphincter slides up into the chest while the diaphragm remains in its normal location. As a result, the pressure normally generated by the diaphragm overlying the sphincter and the pressure generated by the sphincter no longer overlap, and as a result, the total pressure at the gastro-esophageal junction decreases. Second, when the gastro-esophageal junction and stomach are pulled up into the chest with each swallow, the sharp angle where the esophagus joins the stomach becomes less sharp and the valve-like effect is lost. Both changes promote reflux of acid.

How is a hiatal hernia diagnosed?

Hiatal hernias are diagnosed incidentally when an upper gastrointestinal x-ray orendoscopy is done during testing to determine the cause of upper gastrointestinal symptoms such as upper abdominal pain. On both the x-ray and endoscopy, the hiatal hernia appears as a separate "sac" lying between what is clearly the esophagus and what is clearly the stomach. This sac is delineated by the lower esophageal sphincter above and the diaphragm below. The hernia may only be visible during swallows, however.

How is a hiatal hernia treated?

Treatment of large para-esophageal hernias causing symptoms requires surgery. During surgery, the stomach is pulled down into the abdomen, the esophageal hiatus is made smaller, and the esophagus is attached firmly to the diaphragm. This procedure restores the normal anatomy. Since sliding hiatal hernias rarely cause problems themselves but rather contribute to acid reflux, the treatment for patients with hiatal hernias is usually the same as for the associated GERD. If the GERD is severe, complicated, or unresponsive to reasonable doses of medications, surgery often is performed. At the time of surgery, the hiatal hernia is eliminated in a manner similar to the repair of

para-esophageal hernias. However, in addition, part of the upper stomach is wrapped around the lower sphincter to augment the pressure at the sphincter and further prevent acid reflux.

Hiatal Hernia At A Glance

A hiatal hernia is an anatomical abnormality of the esophagus. Hiatal hernias contribute to gastro-esophageal reflux disease (GERD). The symptoms in individuals with hiatal hernias parallel the symptoms of the associated GERD. The treatment of most hiatal hernias is the same as for the associated GERD.

Last Editorial Review: 2/19/2008

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Hiatus Hernia
Author: Frank W. Jackson, M.D. The hiatus hernia is one of the most misunderstood and maligned conditions in medicine. People blame this hernia for much more than it ever does. Patients with a hiatus hernia need to understand what it is and what might occur with it. Most importantly, they need to know it is unusual for serious problems to develop from this type of hernia.

Anatomy
The diaphragm is a sheet of muscle that separates the lungs from the abdomen. When a person takes a deep breath, the dome-shaped diaphragm contracts and flattens. In doing this, the diaphragm pulls air into the lungs. The left diaphragm contains a small hole through which passes the tube-shaped esophagus that carries food and liquid to the stomach. Normally this hole, called a hiatus, is small and fits snugly around the esophagus. The J-shaped stomach sits below the diaphragm.

What Causes a Hiatus Hernia?

In some people, the hiatus or hole in the diaphragm weakens and enlarges. It is not known why this occurs. It may be due to heredity, while in others it may be caused by obesity, exercises such as weightlifting, or straining during bowel movement. Whatever the cause, a portion of the stomach herniates, or moves up, into the chest cavity through this enlarged hole. A hiatus hernia is now present. Hiatus hernias are very common, occuring in up to 60 percent of people by age 60.

What Are the Different Types of Hiatus Hernia?

1. Sliding Hiatus Hernia -- In this most common type of hiatus hernia, the herniated portion of the stomach slides back and forth, into and out of the chest. These hernias are normally small and usually cause no problems or even symptoms. 2. Fixed Hiatus Hernia -- In this case, the upper part of the stomach is caught up in the chest. Even with this hernia, there may be few symptoms. However, the potential for problems in the esophagus is increased.

3. Complicated or Serious Hiatus Hernia -- Fortunately, this type of hernia is uncommon. It includes a variety of patterns of herniation of the stomach, including cases in which the entire stomach moves up in the chest. There is a high likelihood that medical problems will occur with this hernia and that treatment, frequently involving surgery, will be required. Complicated hernias are uncommon.

Symptoms
In most patients, hiatus hernias cause no symptoms. This is especially true of sliding hernias. When symptoms occur, they may only be heartburn and regurgitation, when stomach acid refluxes back into the esophagus. Some patients with fixed hiatus hernias experience chronic reflux of acid into the esophagus, which may cause injury and bleeding. Anemia, or low red blood cell count, can result. Further, chronic inflammation of the lower esophagus may produce scarring and narrowing in this area. This, in turn, makes swallowing difficult, and food does not pass easily into the stomach.

Does Hiatus Hernia Cause Pain and Indigestion?

It is wrong to always blame a hiatus hernia for pain and indigestion. Hiatus hernias generally do not cause acute pain. This symptom may result from other disorders, such as peptic ulcers or even heart disease. Some patients with coronary heart disease fool themselves into believing their discomfort is due to a hiatus hernia. If upper-abdominal pain or indigestion occurs, people should not mislead themselves into thinking the cause is a hiatus hernia. Instead, the patient should seek medical advice.

Diagnosis
Diagnosis of a hiatus hernia is typically made through an upper GI barium x-ray. A complementary test is gastroscopy, or upper-intestinal endoscopy, in which the physician visually examines the esophagus and stomach using a flexible scope while the patient is lightly sedated.

What Are the Complications? The complications of hiatus hernia are:

Chronic heartburn and inflammation of the lower esophagus, called reflux esophagitis Anemia due to chronic bleeding from the lower esophagus

Scarring and narrowing of the lower esophagus causing difficulty in swallowing While sleeping, stomach secretions can seep up the esophagus and into the lungs causing chronic cough, wheezing, and even pneumonia

In addition, the complicated hernia can cause serious problems such as difficulty in breathing or severe chest pain, especially in the elderly.

Treatment
Treatment is called for only when the hernia results in symptoms, such as persistent heartburn or difficulty in swallowing. Acid inflammation and ulceration of the lower esophagus also require treatment. General guidelines for treating heartburn and esophagitis (inflammation of the esophagus) are: Avoid (or use only in moderation) foods and substances that increase reflux of acid into the esophagus, such as: nicotine (cigarettes) caffeine chocolate fatty foods peppermint alcohol spearmint

Eat smaller, more frequent meals and do not eat within 2-3 hours of bedtime. Avoid bending, stooping, abdominal exercises, tight belts, and girdles all of which increase abdominal pressure and cause reflux. If overweight, lose weight. Obesity also increases abdominal pressure. Prescription medications. Certain drugs, such as intestinal antispasmodics, calcium channel blockers, and some antidepressants weaken the muscle strength of the lower espohagus. Elevate the head of the bed 8 to 10 inches by putting pillows or a wedge under the upper part of the mattress or blocks under the bedposts at the head of the bed. Gravity then helps keep stomach acid out of the esophagus while sleeping.

Other Treatments
Drugs -- Some medicines effectively reduce the secretion of stomach acid, while others increase the muscle strength of the lower esophagus, thereby reducing acid reflux.

Surgery -- The complicated hiatus hernia requires surgery occasionally on an emergency basis. Surgery otherwise is reserved for those patients with complications that cannot be handled with medications. The mere presence of a hiatus hernia is not a reason for surgery.

Summary
A hiatus hernia is an extremely common condition which usually does not cause symptoms or problems. However, when it does, the physician can frequently treat the problem effectively with a well-planned program. Surgery is infrequently required to treat a hiatus hernia.

http://www.gicare.com/diseases/hiatus-hernia.aspx

Hiatal Hernia
What is a hiatal hernia?
Hiatal Hernia Care Guide

Hiatal Hernia Hiatal Hernia Aftercare Instructions Hiatal Hernia Discharge Care Hiatal Hernia Inpatient Care En Espanol

A hiatal (heye-AY-tul) hernia (HER-nee-ah), also called a diaphragmatic hernia, is a condition where there is a defect in your diaphragm. The defect affects the hiatus (small opening) in the diaphragm, which the esophagus (food pipe) passes through on its way to the stomach. The defect allows the stomach to pass through the hiatus and bulge upward into the chest. The diaphragm is a muscular wall that separates your chest and abdomen (stomach). With a hiatal hernia, the hiatus in the diaphragm is too large or the muscles around the hiatus are weak. A large opening may allow a part of the stomach to go up into the chest. As the herniated part moves up and down or gets trapped in the chest, it causes acid reflux. This means that the food and acid in the stomach back up into the esophagus. This irritates and damages the esophagus, and may cause a burning feeling in the chest called heartburn.

What causes a hiatal hernia?

The exact cause of a hiatal hernia is not known. Some people may have been born with a large hiatus in the diaphragm. This increases their chance of having a hiatal hernia early in their lives.

Others develop a hiatal hernia as they grow older. The following are possible conditions which may increase your risk of having a hiatal hernia:

Having another family member with a hiatal hernia. Increased pressure inside the abdomen, such as when one is overweight or pregnant. Shortening of the esophagus due to swelling and scarring. This may cause the stomach to be pulled up.

What are the types of hiatal hernia?

There are four types of hiatal hernia:

Type I (sliding hiatal hernia): This occurs when a portion of the stomach slides in and out of the hiatus. This type is the most common and usually causes gastroesophageal reflux disease (GERD). GERD occurs when the lower muscle of the esophagus does not close properly and causes acid reflux. Type II (paraesophageal hiatal hernia): Type II hiatal hernia forms when a part of the stomach squeezes through the hiatus and lies next to the esophagus. Type III (combined sliding and paraesophageal hiatal hernias): Type III hiatal hernia is a combination of a sliding and a paraesophageal hiatal hernia. Type IV (complex paraesophageal hiatal hernia): With this type of hiatal hernia, other abdominal contents are pushed up into the chest. This may include the whole stomach, the small and large bowels, spleen, pancreas, or liver.

What are the signs and symptoms of a hiatal hernia?

Heartburn is the most common symptom of having a hiatal hernia. It is a feeling of burning pain in your chest or below the sternum (chest bone). This usually occurs after meals and spreads to your neck, jaw, or shoulder. You may also have one or more of the following signs and symptoms:

Abdominal pain, especially in the area just above the navel. Bitter or acid taste in your mouth. Choking, coughing, or shortness of breath. Dysphagia (trouble swallowing). Frequent burping or hiccups. Vomiting (throwing up) blood or having black, tarry stools.

Weight loss.

How is a hiatal hernia diagnosed?

You may have any of the following:

Barium swallow: This test is an x-ray of your throat and esophagus, the tube connecting your throat to your stomach. This test may also be called a barium esophagram. You will drink a thick liquid called barium. Barium helps your esophagus and stomach show up better on xrays. Follow the instructions of your caregiver before and after the test. Endoscopy: This test uses a scope to see the inside of your digestive tract. A scope is a long, bendable tube with a light on the end of it. A camera may be hooked to the scope to take pictures. During an endoscopy, caregivers may find problems with how your digestive tract is working. Samples may be taken from your digestive tract and sent to a lab for tests. Small tumors may be removed, and bleeding may be treated during an endoscopy. Esophageal manometry: This test measures the pressure within the esophagus and stomach. Esophageal pH monitoring: A small probe is placed inside the esophagus and stomach to check the pH of your stomach acid. The pH measures how much acid is in your stomach. This test also measures the amount of acid that goes into the esophagus. Upper GI x-rays: During an upper GI series, an x-ray machine is used to take pictures of your stomach and intestines (bowel). You may be given a chalky liquid to drink before the pictures are taken. This liquid helps your stomach and intestines show up better on the x-rays. An upper GI series can show if you have an ulcer, a blocked intestine, or other problems.

How is a hiatal hernia treated?

Your caregiver may suggest that you make diet and lifestyle changes. You may also need any of the following:

Medicines: Medicines may be given to relieve the symptoms caused by a hiatal hernia, such as acid reflux. These may include antacids and medicines for vomiting, frequent burping, and hiccups. Surgery: Surgery may be done when your medicines cannot control your symptoms or other problems are present. Your caregiver may also suggest surgery depending on the type of hernia you have. Surgeries may include the following:
o

Putting your herniated stomach back into its normal location or fixing your esophagus problem. Making the hiatus smaller and anchoring your stomach in your abdomen.

Fundoplication: Fundoplication is a surgery that wraps the upper part of the stomach around the esophageal sphincter to strengthen it. A sphincter is a ringlike muscle that opens and closes an opening in your body.

Ask your caregiver for more information about these surgeries to repair your hiatal hernia. With treatment, such as medicine, and lifestyle changes, your hiatal hernia symptoms may be relieved and your quality of life improved.

Where can I find more information?

Having a hiatal hernia may be a life-changing disorder for you and your family. Accepting that you have a hiatal hernia may be hard. Talk to your caregivers, family, or friends about your feelings. Your caregiver can help your family better understand how to support a person with a hiatal hernia. Contact the following for more information:

American Academy of Family Physicians 11400 Tomahawk Creek Parkway Leawood , KS 66211-2680 Phone: 1- 913 - 906-6000 Phone: 1- 800 - 274-2237 Web Address: http://www.aafp.org National Digestive Diseases Information Clearinghouse (NDDIC) 2 Information Way Bethesda , MD 20892-3570 Phone: 1- 800 - 8915389 Web Address: www.digestive.niddk.nih.gov

Care Agreement
You have the right to help plan your care. Learn about your health condition and how it may be treated. Discuss treatment options with your caregivers to decide what care you want to receive. You always have the right to refuse treatment. Copyright 2011. Thomson Reuters. All rights reserved. Information is for End User's use only and may not be sold, redistributed or otherwise used for commercial purposes. The above information is an educational aid only. It is not intended as medical advice for individual conditions or treatments. Talk to your doctor, nurse or pharmacist before following any medical regimen to see if it is safe and effective for you.

Hiatus hernia: Treatment, symptoms, advice & help

About Hiatus hernia
Hiatus hernia is a common gastro-intestinal problem characterised by the protrusion of the stomach into the chest cavity via an opening in the diaphragm called as the oesophageal hiatus. Most of the times, it is an incidental finding due to absence of any characteristic symptoms.

Hiatus hernia: Incidence, age and sex

Hiatus hernia may occur at any age, but its chances increases with increasing age due to loss of elasticity and muscle weakening as a process of aging. Hiatus hernia is more frequently encountered in women as compared with men.

Signs and symptoms of hiatus hernia: Diagnosis

Hiatus hernia is usually asymptomatic and do not present with any clinical features. Thus hiatus hernia in most cases is an incidental finding. However it may be associated with gastro-oesophageal reflux disease in most of the individuals. The symptoms of gastro-oesophageal reflux disease like pain in the epigastric region, a bloating sensation or regurgitation may also be present. A detailed history and physical examination, in most cases may point towards the diagnosis of hiatus hernia. However, it is usually an incidental finding during routine investigations. Upper gastro-intestinal x-ray or even endoscopy may help in establishing the diagnosis.

Causes and prevention of Hiatus hernia

Hiatus hernia occurs due to loss of elasticity and weakness of the muscles, controlling the oesophageal opening in the diaphragm. Thus, its chances of occurrence are more in older individuals. Increase intra-abdominal pressure as in pregnancy, ascitis or obesity is an important factor in the causation of hiatus hernia. Moreover, several conditions are known to predispose individuals to hiatus hernia and these conditions include chronic cough, persistent constipation, straining during bowel movement. Heavy-weight lifting or tight clothing may also lead to hiatus hernia. Regular physical exercise, balanced diet and maintaining optimal weight may help in preventing this condition. Moreover, drinking ample water and taking a high fibre diet may help in preventing constipation. Smoking cessation and avoidance of lifting heavy objects may also help in preventing the occurrence of Hiatus hernia.

Hiatus hernia: Complications

Hiatus hernia, in most of the cases is asymptomatic, leading to its long-standing presence without treatment. This may lead to increased chances of complications, which include damage and inflammation of the oesophageal wall and even oesophageal ulcer, resulting in bleeding in some individuals. This, in turn may result in iron deficiency anaemia.

Hiatus hernia: Treatment

The treatment of hernia may include both medical and surgical modality, depending upon the severity of the hernia. The medical treatment is same as that of gastro-oesophageal disease, and includes antacid medications which provide symptomatic relief. Other medications like proton pump inhibitors and H2 antagonists can be prescribed to suppress the production of gastric acid. Severe cases of hernia may require surgical correction and include restoration of the normal anatomy by pulling down the stomach in the abdominal region and making the oesophageal opening smaller. It is advisable for the individual to maintain a follow-up consultation with the doctor to monitor any recurrence in the future.

What Is A Hiatal Hernia?

A hernia is a protrusion of an organ through a wall of a cavity in which it is enclosed. In the case of a hiatal hernia, a portion of the stomach protrudes through a teardrop-shaped hole in the diaphragm where the esophagus and the stomach join. What Causes Hiatal Hernia? The most frequent known cause of hiatal hernia is an increased pressure in the abdominal cavity produced by coughing, vomiting, straining at stool, or sudden physical exertion. Pregnancy, obesity, or excess fluid in the abdomen also contribute to causing this condition. Who Gets Hiatal Hernia? Hiatal hernias may develop in people of all ages and both sexes, although it is considered to be a condition of middle age. In fact, the majority of otherwise normal people past the age of 50 have small hiatal hernias. Are Hiatal Hernias and Heartburn Associated? For many years, many people, including some doctors, thought that heartburn was a result of having a hiatal hernia. It is now known that small hiatal hernias are common and usually harmless. While heartburn is sometimes associated with hiatal hernia, it is not caused by it. Heartburn occurs when the sphincter located at the junction of the esophagus and the stomach (called the LES) either relaxes inappropriately or is very weak. This allows the highly acidic contents of the stomach to back up into the esophagus. The backwash of stomach contents, known as reflux, irritates the lining of esophagus and causes heartburn. Are There Any Complications Associated with Hiatal Hernia? Most hiatal hernias do not need treatment. However, if the hernia is in danger of becoming strangulated (constricted in such a way as to cut off the blood supply) or is complicated by esophagitis (inflammation of the esophagus), treatment becomes necessary. To prevent strangulation, your doctor may perform surgery to reduce the size of the hernia. Treatment of esophagitis is necessary to prevent ulcers (sores) from forming in the lining of the esophagus. When these sores heal, they can leave scars that can make it difficult or impossible to swallow. In some people, long-term esophagitis may result in Barrett's esophagus, a condition thought to be a precursor of cancer. (See the Digestive Diseases Clearinghouse fact sheet "Heartburn" for more information.) Most cases of esophagitis respond to antacids, weight reduction, and a common sense approach to eating, drinking, and other lifestyle habits. Remember, if prolonged use of antacids becomes necessary, see your doctor. Long-term use of antacids can produce side effects like diarrhea, altered calcium metabolism, and magnesium retention. If the esophagitis persists, your doctor may perform surgery to restore the stomach to its proper position and strengthen the area around the opening. COPYRIGHT 1990 National Institute of Diabetes & Digestive & Kidney Diseases

COPYRIGHT 2004 Gale Group

Hiatal Hernia

What Is a Hiatal Hernia?

When an organ pokes out past the muscle wall that is supposed to hold the organ in place, you have a hernia. A hiatal hernia occurs when the upper part of the stomach pushes through an opening in the diaphragm, the muscle that separates the abdomen from the chest. This opening is called the esophageal hiatus. After you swallow food, it travels between your mouth and stomach through a muscular tube called the esophagus. The esophagus passes through the hiatus to enter the abdominal cavity. At the bottom of the esophagus is a muscle called the lower esophageal sphincter, which acts as a valve. The hiatus itself acts like a second valve. Normally the hiatus and the lower esophageal sphincter line up with each other to keep stomach contents from backing up into the esophagus (a condition called reflux). But the hiatus can stretch because of muscle weakness or too much abdominal pressure. When this occurs, the stomach can slip through the hiatus, causing a hiatal hernia. A hiatal hernia can be caused by:

obesity pregnancy tight clothing sudden physical exertion, such as weight lifting straining, coughing abdominal injury

Although most hiatal hernias cause no symptoms, some people experience heartburn. Heartburn is caused by gastric reflux, in which the acid from the stomach refluxes up into the esophagus, causing an irritating and burning sensation. People with reflux symptoms have gastroesophageal reflux disease (GERD) and may need drug therapy. In certain people, reflux damages the lining of the esophagus, resulting in erosions. In extreme cases, the normal lining is replaced by abnormal cells, a condition called Barrett's esophagus. You should not worry about having a hiatal hernia. Many people over the age of 50 have such a hernia, and it does not need treatment unless heartburn or GERD is present and causes significant discomfort, or unless the hernia is in danger of becoming twisted and cutting off the stomach's blood supply. Treatment may also be considered if you have complications such as severe GERD or esophagitis, which is an inflammation of the esophagus. In such cases, the doctor may recommend surgery to repair the hiatal hernia. If a hiatal hernia is causing symptoms, the following tips may help: Costochondritis - which is inflammation of the cartilage of your rib cage, particularly the cartilage that joins your ribs to your breast bone or sternum. This pain may occur suddenly and be intense, which may cause some people to assume that it is a heart attack. However, with costochondritis it hurts when you push in your sternum or the ribs near the sternum. Heart attack pain is usually more wide spread and the chest wall usually is not tender. This is treated with rest, heat, and nonsteroidal anti-inflammatory drugs such as ibuprofen. Miscellaneous Causes

Eat smaller, more frequent meals. Avoid foods and drinks that may cause symptoms. Avoid lying down for 3 hours after eating. Raise the head of your bed 4 to 8 inches. Avoid wearing tight clothing around your waist. Take acid-reducing medications. Lose weight

What is Barrett's esophagus?

Barrett's esophagus is a complication of chronicgastroesophageal reflux disease(GERD), primarily in white men. GERD is a disease in which there is reflux of acidic fluid from the stomach into the esophagus (theswallowing tube). It most commonly causes heartburn. There are two requirements for the diagnosis of Barrett's esophagus. The requirements necessitate an endoscopy of the esophagus. During endoscopy, a long flexible tube with a light and camera at its tip (an endoscope) is inserted through the mouth and into the esophagus to view and biopsy (sample tissue from) the lining of the esophagus. The two requirements are: 1. At endoscopy, an abnormal pink lining should be seen as replacing the normal whitish lining of the esophagus. This abnormal lining extends a short distance (usually less than 2.5 inches) up the esophagus from thegastroesophageal junction(the GE junction, which is where the esophagus joins the stomach). 2. Microscopic evaluation of the biopsy of this abnormal lining should shows that the normal lining cells of the esophagus have been replaced by intestinal type lining cells, including mucusproducing cells called goblet cells. Other cells also are present, some of which resemble cells that line the stomach. However, if intestinal goblet cells are not present, the diagnosis of Barrett's esophagus should not be made. Barrett's esophagus is officially coded by the Library of Congress for electronic searches of the literature as Barrett esophagus, but Barrett's esophagus (with the apostrophe "s") is the name used universally. The condition is named after a surgeon, Norman Barrett, who described the condition. However, it turns out that his interpretation of the findings was not correct. In 1953, Doctors' Allison and Johnstone actually described this condition as we now understand it, namely that metaplasia was occurring. (Metaplasia, which is discussed below, is the term used when one adult tissue replaces another.) Nevertheless, the condition has been immortalized with Barrett's name. Initially, it was thought that the Barrett's esophagus consisted of stomach (gastric) tissue replacing the usual squamous tissue lining the esophagus. However, in the mid 70's, Dr. Paull and colleagues published a paper in which they described the mucosa (inner lining) of Barrett's esophagus in greater detail than had been done previously. They pointed out that Barrett's esophagus consisted of a metaplasia in which the normal cells lining the esophagus were replaced by a mixture of gastric and intestinal lining cells. The intestinal-type lining cells also are called specialized columnar cells which include goblet cells. For a number of years, some scientists thought that there were two types of Barrett's; one in which the normal lining was replaced with stomach (gastric) type cells only, and the second in which intestinal cells were present. However, the current belief is that only the presence of intestinal-type goblet cells establishes the diagnosis of Barrett's esophagus, regardless of what other cell types are present.

What causes Barrett's esophagus?

Gastroesophageal reflux disease (GERD)

GERD causes Barrett's esophagus. The esophagus is a muscular tube that is located in the chest and serves to transfer food from the mouth to the stomach. The lower esophageal sphincter (LES) is a valve that is located at the junction of the stomach with the esophagus . Its function is to prevent acid and other contents of the stomach from coming back into the esophagus. GERD is a condition in which excessive acid-containing fluid refluxes (flows) back into the esophagus, in part because the lower esophageal sphincter is weak. The weakness of the LES may be related, in part, to the fact that virtually all GERD patients have hiatal hernia. In hiatal hernia, the upper few centimeters of the stomach slides back and forth between the abdomen and the chest through the diaphragm. This sliding may interfere with how the sphincter works as a barrier to reflux from the stomach to the esophagus. Previously, the term hernia was used instead of GERD in explaining to patients the basis of their symptoms (usually heartburn) because virtually all GERD patients have hiatal hernias. GERD, however, is the more accurate term. Hiatal hernias are extremely common in the population and yet only a small number of people with hiatal hernia develop GERD. In other words, the presence of a hiatal hernia does not mean that the person will develop GERD. On the flip side, however, if a person has GERD, hiatal hernia is almost always present. Thus, Barrett's esophagus is caused by chronic (of many years duration) and usually severe acid reflux. In some patients with GERD, the esophagus reacts to the repeated injury from the acidic fluid by changing the type of cells lining it from squamous (normal cells) to columnar (intestinal-type cells). This transformation, called metaplasia, is believed to be a protective response because the specialized columnar epithelium (epithelium means lining) in Barrett's esophagus is more resistant to injury from acid than the squamous epithelium. Picture of gastroesophageal reflux disease (GERD)

Other contributors to Barrett's esophagus The fluid in the stomach contains acid that is produced by the stomach. In addition, however, the fluid may contain bile acids (from bile produced by theliver) and enzymes (produced by the pancreas) that have refluxed back from the duodenum into the stomach. (The duodenum is the first part of the small intestine just beyond the stomach.) The acid that refluxes from the stomach to the esophagus is injurious to the esophagus. There is some evidence, however, that the bile and pancreatic enzymes combined with the acid may be more injurious than acid alone.

Who develops Barrett's esophagus?

Approximately 10% to 15% of individuals with chronic symptoms of GERD develop Barrett's esophagus, and it is estimated that Barrett's esophagus may affect as many as one in 100 to one in 500 individuals in the general Caucasian population, especially among males. Not everyone with GERD has symptoms of GERD, however. Therefore, some people with Barrett's are unaware that they have Barrett's because they have GERD without any symptoms at all or have very mild and infrequent symptoms. It is unclear why Barrett's esophagus is so overwhelmingly more common in white males than in any other group. For example, although women and African-Americans do not seem to be protected from developing GERD, they are largely protected (especially African-Americans) from developing Barrett's esophagus and Barrett's cancer (adenocarcinoma). There is evidence that in the western hemisphere, esophageal cancer and cancer of the gastroesophageal junction (called cardia cancer) are increasing in frequency, perhaps more so than any other gastrointestinal tract cancer. (You should know, however, that colon cancer is still very much more common than esophageal cancer.) Barrett's esophagus may run in some families and be genetically determined. Studies are underway to determine if any genes or markers can be found in these families that would predict the development of Barrett's esophagus in the general population. In these families with Barrett's as well as with Barrett's in the general population, GERD is the common denominator. However, the question is why the Barrett's occurs more commonly in these families than in others with comparably severe GERD, but with no family association.