A paraesophageal hernia is a displacement of anatomical structures into the chest cavity through the diaphragm. The disease is serious and requires surgical treatment. It is also quite rare, occurring in only 0.5-1% of all hernia cases.
What are the causes of this pathology? What are the prerequisites? And by what symptoms can you learn about its development? These and many other questions are answered in the article.
Briefly about pathology
The lower part of the esophagus (cardia) under normal conditions performs a barrier function. It prevents organs from the abdominal cavity from entering through the diaphragmatic opening. However, under the influence of negative factors, the protective force weakens. Because of this, the organs penetrate into the chest cavity. Of course, this pathological phenomenon is accompanied by a feeling of heaviness and specific symptoms (they will be listed below).
Sometimes wall weakness is calledinsufficiency of the cardia. This phenomenon is accompanied by an increase in the level of pressure in the abdominal cavity, and its decrease in the chest.
As a rule, the presence of this pathology is detected during the examination by a gastroenterologist. The older the organ from a physiological point of view, the higher the risk of paraesophageal hernia. With age, chronic diseases get stronger, develop, and this contributes to the protrusion of the abdominal organs.
According to statistics, patients whose age does not exceed 35 years old experience this disease in 40% of cases. After age 60, the risk increases to 60%. As a rule, paraesophageal hernia occurs more often in women. This is due to the anatomical features of their body.
Provoking factors
Hiatal hernia (ICD-10 code: K44) is caused by chronic respiratory diseases and high abdominal pressure. However, precipitating factors can always arise. These include:
- Diseases that are accompanied by connective tissue disorders - hemorrhoids, flat feet, Marfan's syndrome and varicose veins.
- Diseases of the gastrointestinal tract associated with dysmotility: chronic pancreatitis, dyskinesia, gastroduodenitis, ulcers.
- Hernia of the umbilical region, white line of the abdomen, femoral protrusion.
- Weakness of the ligamentous apparatus of the diaphragm of an acquired nature.
- A sharp increase in pressure, which can provoke a chronicconstipation, profuse vomiting, abdominal injury or increased activity.
- Re-pregnancy.
- Scarring and deformity of the esophagus.
- Hormonal disorders.
- Operations on the abdominal organs.
It is important to note that hiatal hernia (ICD-10 code: K44) can begin to develop not only at some specific point in life - it can also be congenital.
Sliding hernia
Like any other disease, this pathology has several forms of manifestation. Two, to be precise. The difference between a sliding hernia and a paraesophageal (fixed) hernia is that it is diagnosed with a protrusion through the natural opening of those organs that are below the diaphragm.
This form of pathology develops as a result of weakening of the ligaments of muscle connective tissues and due to their reduced elasticity.
From the etiological factors are:
- Increased abdominal pressure.
- Impaired motility of the digestive tract.
- The presence of pathologies of a chronic nature that relate to the liver, stomach, respiratory tract.
- Weakness of the ligamentous apparatus and other connective tissue elements.
Talking about the causes and symptoms of hiatal hernia (treatment will be discussed later), it should be noted that among all gastrointestinal ailments, this pathology takes 3rd place, it occurs a little less often than ulcers and cholecystitis.
Fixed hernia(HML)
It is less common than the form mentioned above. In this case, part of the stomach is simply pushed out through the diaphragm, where it then remains. This pathology has a risk - blood flow to the organ may be blocked. And this is fraught with serious damage.
The most common pathology is manifested by belching. It occurs due to air entering the esophagus. Sometimes it is there along with an admixture of gastric juice or bile. In this case, the burp acquires a characteristic smell and taste.
Often, people suffering from a fixed hernia complain of severe pain in the region of the heart. This does not mean that they have problems of this nature. It's just that the pain they feel really mimics heart pain.
HH degrees
Early diagnosis of hiatal hernia helps to avoid severe complications and the development of the disease. At an early stage, it is quite possible to do without surgical intervention. And there are three of them:
- First. The lightest. It is characterized by elevation of the esophagus into the chest cavity. The size of the hole prevents the stomach from reaching the top, so it stays in place.
- Second. In the chest cavity there is already a whole abdominal section of the esophagus. A part of the stomach is observed in the region of the opening of the diaphragm.
- Third. It is characterized by the fact that most of the stomach (sometimes even up to the pylorus) rises into the chest cavity.
Signs of disease
Having studiedcauses of paraesophageal hernia, you can proceed to consider the symptoms that indicate its presence. The most striking signs include:
- Pain syndrome localized in the epigastrium. It radiates to the back and the area between the shoulder blades, spreading along the esophagus.
- Increased pain after exertion and eating. The same is observed with deep inspiration and intestinal flatulence.
- Discomfort in retrosternal pain.
- Hiccups, burning throat, heartburn, hoarseness and retching.
- High blood pressure.
- Vomiting blood, cyanosis.
- Violent bouts of coughing, especially at night. May be accompanied by increased salivation and choking.
Pain differentiation
Unpleasant sensations arising from a paraesophageal hernia can be distinguished based on the following signs:
- Pain occurs during physical exertion, after eating food, as well as with increased gas formation and during a long stay in a horizontal position.
- Discomfort disappears or improves after burping, deep breathing, changing positions or drinking.
- Increases pain from bending forward.
- Sometimes the discomfort is girdle-like, reminiscent of pancreatitis.
Pain can be accompanied by heartburn, hiccups, discomfort in the tongue (perhaps even burning), hoarseness, nausea, vomiting, and an inability to pass gases and empty the intestines.
Complications
What is dangerous paraesophageal hernia? If left untreated, there will be complications. Namely:
- Gastrointestinal bleeding caused by erosion of the stomach of the esophagus, peptic ulcers.
- Reflux esophagitis.
- Perforation of the stomach wall and incarcerated hernia.
- Anemia.
Less commonly, the consequences of a paraesophageal hernia are intussusception of the esophagus and retrograde prolapse of the mucosa. These complications are identified during endoscopy and fluoroscopy.
Diagnosis
It is necessary to talk about its implementation before discussing the principles of therapy and treatment. The symptoms of a hiatal hernia are specific, and therefore, if you notice any of the manifestations of the previously listed, you should go to a gastroenterologist.
After a survey and visual inspection, instrumental studies are carried out:
- X-ray with contrast.
- Manometer and endoscopy.
- Complete blood count.
- Ultrasound of the abdomen.
- Electrocardiography.
Other activities may be required. It all depends on the patient's history and the characteristics of his body.
Principles of Therapy
The causes and symptoms of diaphragmatic hernia were discussed above. Treatment also needs to be described. It starts with conservative therapy. It is aimed at eliminating the symptoms of gastroesophageal reflux.
But in general, based on clinicalsigns and pathogenetic mechanisms, the tasks of therapy can be formulated as follows:
- Reducing the aggressive properties of juice secreted by the stomach. Reducing the content of hydrochloric acid in it.
- Restriction and prevention of gastroesophageal reflux.
- Reduce gastric and esophageal dyskinesia. Ideally, its complete elimination.
- Local effect of drugs on the inflamed mucosa.
- Restriction and prevention of injuries in the prolapsing part of the stomach, as well as in the hernial ring of the esophageal abdominal segment.
Indicated drugs
Since we are talking about eliminating the symptoms of diaphragmatic hernia and treating this disease, it is necessary to list the medicines that can help cope with it. They are selected by the doctor on an individual basis, but, as a rule, the following remedies are prescribed:
- H2-histamine receptor blockers. Minimize acid production.
- Antacids. They neutralize stomach acid.
- Proton pump inhibitors. They are effective means in eliminating acid-dependent diseases of the stomach.
- Combined drugs: "Omez", "Pantoprazole", "Ranitidine", "Omeprazole", "Gastrozol". They combine the action of blockers and inhibitors.
- Prokinetics. They positively affect the mucous membrane of the esophagus and stomach, optimize their motility, relieve pain and nausea. The best drugs are Trimebutin, Motilak, Itomed, Motilium, Ganaton and Metoclopramide.
- Vitamins of group B. They must be taken,to accelerate the regeneration of stomach tissue.
Surgery
Surgery is the most effective way to repair a hernia. And the only true method in cases where conservative therapy is ineffective.
The operation is carried out after a detailed examination and careful preparation. An intervention is planned, but occasionally there are emergencies due to bleeding, perforation or infringement.
Recently, the Nissen fundoplication has been performed more frequently. The principle of the operation is to create a cuff from a part of the wall of the stomach, which is fixed around the hole with expansion.
They operate in two ways. An open incision can be performed, or laparoscopy, which involves the use of an endoscope.
There are contraindications. Among them:
- Exacerbation of chronic ailments.
- Blood diseases.
- Diabetes mellitus (uncompensated).
- Infectious diseases.
- Respiratory failure, lung problems.
- Decompensated heart diseases.
- Oncological neoplasms.
- Pregnancy.
- Recent abdominal surgery.
Rehabilitation takes time. The stitches are removed after a week, all this time the person must take painkillers, antibiotics and prokinetics (if motor skills are impaired).
Diet
Of coursewith a hernia of the esophageal opening of the diaphragm, the patient's menu will have to be revised. The following foods will need to be introduced into the diet:
- Slimy cereal soups.
- Dried bakery products made from wheat flour.
- Dairy products.
- Pasta and porridge.
- Low-fat fish and meat, steamed or baked/boiled.
- Animal and vegetable oils.
- Pure vegetables and fruits, kissels, vegetable soups, kissels.
You will need to give up sugar, spices, everything s alty, spicy, fatty, spicy. Take food 5-6 times a day, do not lie down for 60 minutes after eating. Eat dinner at least 2-3 hours before bed. Before meals, it is recommended to consume 1 tbsp. l. olive oil. Smoking is also prohibited.
And as a preventive measure, it is recommended to drink a decoction of chamomile or tea with calendula. Drinks are prepared in an elementary way - 2-3 tbsp. l. herbs are poured with boiling water. Before use, they insist and filter.
