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Is there one more than one type of hiatal hernia?
The most common type of hiatal hernia is a sliding hiatal hernia. This accounts for 95% of all hiatal hernias and, because a hiatal hernia by itself causes no symptoms, it is unknown how frequently this condition exists in the general population. With a sliding hernia, the GE junction and a portion of the stomach slides upward into the mediastinum, the space in the chest between the lungs where the esophagus travels and where the heart is housed. The hernia is more prominent during inspiration when the diaphragm contracts and descends towards the abdominal cavity and when the esophagus shortens during swallowing.
In a paraesophageal hernia, the gap in the phrenoesophageal membrane is larger, and a greater portion of the stomach herniates into the chest alongside the esophagus and stays there, but the GE junction remains below the diaphragm. This is due to ligaments that keep parts of the stomach attached to other organs within the abdomen, and, should a paraesophageal hernia occur, parts of the stomach rotate upward to assume their position above the diaphragm.
In a combination of events, should the defect in the diaphragm become larger, the GE junction and more of the stomach can herniate and become displaced into the chest causing both a paraesophageal and a sliding hiatal hernia.
What are the signs and symptoms of a hiatal hernia?
By itself, a hiatal hernia causes no symptoms, and most are found incidentally when a person has a chest X-ray or abdominal X-rays (including upper GI series, and CT scans, where the patient swallows barium or another contrast material). It also is found incidentally during gastrointestinal endoscopy of the esophagus, stomach and duodenum (EGD).
The stomach is a mixing bowl that allows food and digestive juices to mix together to begin the digestive process. The stomach has a protective lining that prevents acid from eating away at the stomach muscle and causing inflammation. Unfortunately, the esophagus does not have a similar protective lining. Instead it relies on the lower esophageal sphincter (LES) located at the GE junction and the muscle of the diaphragm surrounding the esophagus to act as a valve to prevent acid from refluxing from the stomach into the esophagus. In addition to the LES, the normal location of the GE junction within the abdominal cavity is important in keeping acid where it belongs. There is increased pressure within the abdominal cavity compared to the chest cavity, particularly during inspiration, and the combination of pressure exerted within the lowermost esophagus from the LES, the diaphragm and the abdominal cavity creates a zone of higher pressure that keeps stomach acid in place.
In the situation of a sliding hiatal hernia, the GE junction moves above the diaphragm and into the chest, and the higher pressure zone is lost. Acid is allowed to reflux back into the esophagus causing inflammation of the lining of the esophagus and the symptoms of GERD.
These symptoms may include the following:
- heartburn: chest pain or burning,
- nausea, vomiting or retching (dry heaves)
- waterbrash, the rapid appearance of a large amount of saliva in the mouth that is stimulated by the refluxing acid
Symptoms usually are worse after meals. These symptoms may be made worse when lying flat and may resolve with sitting up or walking.
In some patients, reflux into the lower esophagus sets off nervous reflexes that can cause a cough or even spasm of the small airways within the lungs (asthma). A few patients may reflux acid droplets into the back of their throat. This acid can be inhaled or aspirated into the lung causing coughing spasms, asthma, or repeated infections of the lung including pneumonia and bronchitis. This may occur in individuals of all ages, from infants to the elderly.
Most paraesophageal hiatal hernias have no symptoms of reflux because the GE junction remains below the diaphragm, but because of the way the stomach has rotated into the chest, there is the possibility of a gastric volvulus, where the stomach twists upon itself. Fortunately, paraesophageal hernias are relatively uncommon. However, volvulus is a surgical emergency and causes difficult, painful swallowing, chest pain, and vomiting.