How to recognize a hiatal hernia (HH)? varieties and treatment. Axial hiatal hernia (sliding and fixed)

A hiatal hernia is a pathological condition with a chronic course in which a section of the esophageal tube, the cardiac part of the gastric cavity and sometimes loops of the small intestine move into the sternum (through the esophageal opening in the diaphragm). This disease is quite common, and patients from the middle and older age categories suffer from it more often. It is worth noting that it is detected more often in the fair sex than in men. A hiatal hernia has several degrees of development, which are divided depending on which organs are displaced into the chest cavity.

Many people have early stages As the disease progresses (degree 1–2), the symptoms of the pathology may not appear at all, which is why they do not take any measures to treat the disease. This is where the danger of hiatal hernia lies - it is asymptomatic, but at any moment it can make itself felt with a vivid clinical picture and complications (the most unfavorable is strangulation with necrosis). It is important to immediately contact a qualified gastroenterologist when you express the first symptoms that may suggest such a pathological condition. Only after diagnostic measures he will be able to identify whether a person is progressing to grade 1, 2 or 3 hiatal hernia, and prescribe comprehensive treatment.

In total, clinicians distinguish three degrees of hiatal hernia. There is no way to independently determine them. For diagnosis, instrumental diagnostic methods will be required. Each degree is characterized by its own clinical picture and some features of its course.

1st degree

Grade 1 hiatal hernia is characterized by penetration into the sternum only of the lower portion of the esophageal tube. In this case, the pylorus is located at the level of the diaphragm. The gastric cavity rises slightly and is located below the diaphragmatic dome, tightly adjacent to it. At stage 1, the patient does not worry about any symptoms indicating progression of the disease. Rarely, minor discomfort in the sternum area and mild pain may occur. The presence of a hiatal hernia can be detected at this stage only through ultrasound diagnostics or radiography. As a rule, organ displacement is discovered randomly. An examination or palpation will not bring any results, since the hernia will not be palpable due to its deep location.

It is worth noting that stage 1 hiatal hernia responds well to conservative therapy. In order to normalize the condition, doctors prescribe a special diet, which involves avoiding fatty, spicy, smoked foods, as well as alcoholic and carbonated drinks. You should eat food up to six times a day, but in small portions - this technique will help reduce the load on the human digestive tract, and on the esophagus and stomach in particular. In addition, it is important to normalize your daily routine and not wear clothes that squeeze your stomach.

2nd degree

In the second degree of esophageal hernia, the lower section of the esophageal tube moves into the chest cavity through the hole in the dome of the diaphragm; the pylorus (cardia) is localized at the level of the hole, as well as part of the stomach. Symptoms indicating progression of the disease become more and more pronounced. A person may complain about painful sensations in the sternum, discomfort, belching, burning sensation. In the second degree, the process of passing food bolus may be disrupted, but not in all clinical situations.

At grade 2, conservative treatment is also possible. The patient is necessarily prescribed exactly the same diet as in the first degree, but in addition, some medications may be included in the treatment plan. In particular, such as antispasmodics, drugs with enzymes, proton pump blockers, and heartburn medications. With stage 2 hiatal hernia, as with stage 1, it is possible to prescribe certain traditional medicine medications. They are prescribed only by a doctor. Self-prescription and uncontrolled use of any decoctions, tinctures and other things can lead to increased symptoms and a deterioration in a person’s condition.

3rd degree

This is the most severe and dangerous degree of hiatal hernia in terms of the development of complications. It is characterized by the fact that not only the lower part of the esophageal tube is displaced into the sternum, but also the cardia (pylorus), the upper part of the stomach. In especially severe cases, displacement of the antrum of the organ and loops of the small intestine may be observed. The clinical picture is expressed very clearly. The patient exhibits the following symptoms:

• painful sensations in the chest area;
• belching;
• paroxysmal heartburn. Most often, this unpleasant symptom is expressed after consumption by a person. food products or when taking a horizontal position;
• . This term in medicine is used to refer to a condition in which a person cannot swallow a bolus of food due to cicatricial narrowing esophagus. In turn, this pathology occurs due to a constantly progressive inflammatory process in the esophageal tube caused by reflux of hydrochloric acid from the gastric cavity;
• regurgitation is a process in which consumed food from the stomach cavity enters the esophageal tube or oral cavity without the manifestation of the urge to vomit, as happens in a normal state;
• Due to the reflux of the contents of the gastric cavity into the esophageal tube and respiratory tract, tracheitis and bronchitis may worsen.

The third degree of the disease is treated only surgically. The most common methods used in treatment include laparoscopy, Topeplasty and Nissen fundoplication. In addition, it is worth noting that simultaneously with the operation, dietary nutrition and drug therapy are prescribed (proton pump blockers, antacids, antispasmodics, enzymes, agents that normalize the secretion of hydrochloric acid, and others).

If surgical intervention is not carried out in a timely manner, the following complications may begin to progress:

• shortening of the esophageal tube;
• bleeding from gastrointestinal tract(manifested by bloody vomiting, black feces, pale skin, anemia and other signs);
• peptic strictures of the esophageal tube;
• heart rhythm disturbance;
• anemia;
• strangulated hernia;
• hemoptysis;
• dysuric disorders;
• phrenopyloric syndrome.

Similar materials

Hernia hiatus diaphragm - pathology chronic, affecting organs digestive system, during which there is a displacement of those internal organs that, in their normal location, are located under the diaphragm. These organs include the abdominal part of the esophagus and the cardiac part of the stomach. This disorder is diagnosed quite often in gastroenterology, and the percentage of frequency increases depending on the age category of the patient.

A sliding hiatal hernia is a pathological condition characterized by protrusion of the lower part of the esophageal tube, resulting in part of the stomach moving into the chest cavity. In the medical literature, this type of hernia is also called axial or vagus. A sliding hiatal hernia may not manifest itself at all for a long time - the person will not complain of any symptoms. As the disease progresses, some symptoms gradually appear, such as heartburn, belching, etc.

A hiatal hernia is a pathological process in which the opening itself expands, which, in turn, can cause movement of some parts of other abdominal organs into the chest. A large number of reasons, both external and internal, can lead to the formation of such a pathology. Among the main ones are weakening of the esophageal ligaments, the period of bearing a child, chronic constipation, heavy physical activity after eating, unhealthy diet, and obesity. In addition, the causes of such a disorder can be chronic gastrointestinal diseases, abdominal injuries and burns of the esophagus. The main risk group is people over fifty years of age. Almost all patients who have been diagnosed with the disease have a question: is it possible to cure a hernia without surgical intervention? And the answer is positive - conservative therapy helps to completely eliminate the disease.

The esophageal opening of the diaphragm is formed mainly due to its right inner leg, which is formed by Gubarev’s orbicularis muscle. The diaphragmatic-esophageal ligament fixes the distal part of the esophagus and prevents the cardia of the stomach from exiting into the chest cavity during longitudinal contraction of the organ. At the same time, the ligamentous apparatus has sufficient plasticity that does not disrupt normal esophageal motility and movements of the esophagus at the time of vomiting, etc.

In addition to the diaphragmatic-esophageal ligament (Morozov-Savvin ligament), French authors described the so-called Bertelli-Laimer musculotendinous membrane, which fixes the distal part of the esophagus, as well as the Yavar and Rouget muscles. These muscles pull the esophagus upward.

A certain role in maintaining the esophagus in a normal position is played by the subdiaphragmatic fat layer and the natural anatomical and topographic location of the abdominal organs. Resorption of subphrenic adipose tissue, atrophy of the left lobe of the liver and disruption of organ syntopy can contribute to the formation of a hiatal hernia.

At least three groups of factors play a decisive role in the occurrence of hernias:

• weakening of connective tissue structures,
• promotion intra-abdominal pressure,
• dyskinesia digestive tract, in particular the esophagus.

Some exceptions are, perhaps, only diaphragmatic hernias childhood, caused mainly by embryonic disorders and gastrointestinal developmental anomalies. The short esophagus and “thoracic stomach”, devoid of peritoneal cover, are the result of the fact that the peritoneal layers are formed in embryogenesis before the stomach and diaphragm descend to their usual place. By this period of intrauterine development, a normal syntopy of the internal organs has already formed, which are covered by the peritoneum. The shortened esophagus, as it were, retains the stomach in the chest cavity so that it remains without embryonic cover in the postembryonic period.

PAD hernias in elderly people are formed, as a rule, as a result involutionary processes in the ligamentous apparatus and tissues under. This is supported by the fact that in patients over 60 years of age, there is a very frequent combination of diaphragmatic hernias with other hernias, for example, inguinal, umbilical, femoral, and the white line of the abdomen. Clinicians have long noticed the existence of a significant tendency to hernia formation in detrained and asthenized people, as well as in people suffering from certain diseases affecting connective tissue structures (flat feet, varicose veins of the legs, hemorrhoids, intestinal diverticulosis, etc.).

A direct consequence of involutional processes in the ligamentous apparatus of the diaphragm is the expansion of its esophageal opening, which in this case is capable of allowing 2-3 fingers to pass through. This creates a kind of hernial orifice through which, under certain conditions, the abdominal segment of the esophagus or the adjacent part of the stomach can prolapse. In a significant number of cases, the immediate cause causing AP hernias are an increase in intraperitoneal pressure due to, for example, severe flatulence, sudden tension in the muscles of the anterior abdominal wall, abdominal trauma, attacks of uncontrollable vomiting, large abdominal tumors and, finally, pregnancy. Up to 18% of repeatedly pregnant women suffer from this disease.

A strong and persistent cough in chronic nonspecific lung diseases also contributes to a significant (up to 100 mm Hg and above) increase in intra-abdominal pressure. This explains the fact that people suffering from chronic obstructive bronchitis, in 50% of cases they have a hernia of the pancreas as a concomitant disease.

Such a mechanism of hernia formation (a sharp increase in intra-abdominal pressure against the background of weakening of the connective tissue structures of the PAD) is predominantly pulsational. There is at least one more fundamental possibility of prolapse of the abdominal segment of the esophagus and the fundus of the stomach into the chest cavity. This possibility could be upward traction. According to many authors, the occurrence of hernias of the esophagus is facilitated by longitudinal shortening of the esophagus as a result of scar-inflammatory deformation during reflux esophagitis, peptic esophageal ulcer, chemical or thermal burn of the esophagus, etc. The latter, in turn, increases the severity of cardia insufficiency and reflux symptoms -esophagitis, which causes even greater shortening of the esophagus, thereby creating vicious circle. Cause and effect change places.

As a second model of the traction mechanism of hernia formation, longitudinal contractions of the esophagus should be considered within the framework of esophageal hypermotor dyskinesia. As is known, functional diseases of the esophagus are a special case of dyskinesias of the digestive tract as a whole, especially against the background of diseases such as gastric ulcer and duodenum, chronic cholecystitis, chronic pancreatitis and others. Apparently, it is the presence of pronounced esophagospasm that can explain such a frequent combination of the diseases listed above with hernias of the pod.

PAD hernias are observed in 32.5-67.8% of cases peptic ulcer stomach and duodenum, in 52.5% of cases of chronic gastroduodenitis, in 15.8% of cases of chronic pancreatitis, in 4.5-53.8% of cases of chronic cholecystitis.

In some cases, there is a direct proportional relationship between the severity of the diseases mentioned and the size of hernias. The longer the patient’s history of chronic calculous cholecystitis, the more often and the larger the size of a diaphragmatic hernia is detected.

The data presented quite clearly confirm the importance of dyskinesia of the digestive tract and esophagus, in particular, in the formation of hernias.

Dispensary observation of persons with hernias shows that sometimes there is a significant tendency towards an increase in the size of the hernias themselves. From cardiac they turn into cardiofundal, subtotal and total gastric. This process occurs under the influence of the same reasons as the initial herniation. increased intra-abdominal pressure, increasing scar-inflammatory shortening of the esophagus and longitudinal contraction of the muscle layers as a result of esophagospasm with subsequent traction of the stomach into the chest cavity.

The pathogenesis of paraesophageal hernias has its own characteristics. The emergence and development of these hernias are promoted, in principle, by the same groups of factors that cause axial hernias, but in this case the emphasis is placed differently. Without denying the initial role of the traction mechanism, these authors attach decisive importance to the expansion of the POD due to the weakening of the muscular-ligamentous structures that form it, as well as to the increase in intraesophageal pressure. The pathogenetic role of the latter can be so great that if the abdominal segment of the esophagus is sufficiently fixed, the fundus of the stomach or even its antrum falls into the chest cavity.

An increase in the size of paraesophageal hernias often displaces the stomach and abdominal segment of the esophagus to such an extent that the anatomical cardia also exits through the esophageal opening. A paraesophageal hernia transforms into an axial hernia.

Thus, the mechanisms of formation of hernias of both types have much in common. And this commonality determines the similarity of their clinical picture, where the leading place is occupied by the symptom complex of cardia insufficiency, i.e., that condition, the occurrence and development of which is also associated with a significant number of complications of diaphragmatic hernias. Therefore, it is advisable to consider some issues of the pathogenesis of cardia failure.

Pathogenesis (what happens?) during a hiatal hernia (HH)

The lower part of the esophagus, more precisely the place of its transition into the stomach, called the cardia, serves as a kind of barrier that, under physiological conditions, prevents the reflux of gastric and duodenal contents into the esophagus. Conventionally, anatomical and functional cardia are distinguished. The first is noticeable only from the fundus of the stomach (cardia notch). Along the lesser curvature, the esophagogastric transition occurs gradually. The term “functional cardia” most often refers to the so-called lower esophageal sphincter, represented by the circular muscles. Clinicians believe that in humans the muscular lining of the esophagus in the area of ​​its transition to the stomach does not thicken, which is why it cannot be called the cardiac sphincter. However, the pressure in the zone of the gastroesophageal junction is significantly higher than in the thoracic esophagus, which argues in favor of the concept of a functional cardia.

Despite a significant number of works devoted to the study of this issue, the mechanism of the obturator function of the cardia is still unclear. Clinicians identify the following valves that ensure its closure:

• lower esophageal sphincter;
• a muscular loop of the diaphragm that compresses the esophagus;
• rosette of the mucous membrane of the cardia, preventing gastroesophageal reflux;
• diaphragmatic sphincter;
• intra-abdominal portion of the esophagus;
• circular muscle of the stomach.

The meaning of each of the “gates” is not equal. Under certain conditions, any of them can play a leading role. Among other things, the tone of the cardia is noticeably influenced by most of those used in widespread medical practice. medicines, as well as some hormones and mediators. All this must be taken into account to avoid iatrogenic cardia failure.

In practical medicine, the term “cardia failure” has another, broader meaning. It denotes conditions accompanied by an increase in pressure in the abdominal cavity and a decrease in the chest. Without going into the subtle pathophysiological nuances of the significance of each of these factors involved in the obturator mechanism of the cardia, it is advisable to consider those situations in which the pressor gradient in the esophagus-stomach system increases. In other words, what are the prerequisites for the occurrence of gastroesophageal reflux. The only natural condition that affects this pressure difference is the act of breathing. In a standing position, when inhaling at a normal depth, the pressure in the abdominal cavity exceeds that in the thoracic cavity by 14-20 mmHg. Art., and with deep forced inspiration - by 60-80 mm Hg. Art. and more. In this case, the relatively weak lower esophageal sphincter is not “able” to compensate for such a significant difference in pressure, so the diaphragm plays a decisive role here. During inhalation, her legs seem to squeeze the esophagus. This conclusion is based on the results of the analysis of esophagotonograms: the respiratory waves have the greatest amplitude at the level of the POD. Deeper breathing causes these teeth to enlarge.

Features of the location of the transition of the esophagus to the stomach (intra-abdominal portion of the esophagus, cardiac sphincter) also have a certain significance for maintaining the normal obturator function of the cardia. As you inhale, the pressure in the abdominal region of the organ, i.e., under the diaphragm, increases, while as you exhale it decreases. In other words, inspiratory pressure in the lower esophageal sphincter is higher than expiratory pressure.

The interaction of the diaphragmatic clamp and the cardiac sphincter enhances the resistance to gastroesophageal reflux, and it is this mechanism that is disrupted under the influence of hernias in the first place. As mentioned above, in similar cases expansion of the diaphragmatic ring is noted: the intensity of inspiratory compression sharply decreases. In addition, the cardiac sphincter in patients with hernias of the abdominal cavity is displaced upward, into the chest cavity, where it is affected by negative intrathoracic pressure, especially low in the inhalation phase. Further, at this moment, the diaphragmatic legs no longer compress the abdominal segment of the esophagus (it is dystopic upward), but the hernial sac itself, the contents of which are, as it were, injected into the esophageal cavity.

The role of the act of breathing in the formation of gastroesophageal reflux is well illustrated by the results of an X-ray examination of patients with axial hernias of the infraventricular hernia. When examining such patients in horizontal position reflux was detected only during inspiration.

Coughing, sneezing and sudden straining are accompanied by an abrupt increase in intra-abdominal and, to a lesser extent, intrathoracic pressure. U healthy people the increase in the pressure gradient in these cases is compensated by the same mechanism (diaphragmatic crura and tone of the lower esophageal sphincter), the breakdown of which, due to the above circumstances, provokes reflux. This can explain the frequent appearance of the latter in people with various chronic nonspecific lung diseases in combination with hernias of the lower back.

Situations associated with strong bending of the torso back, as well as with raising outstretched legs in a lying position (rhythmic gymnastics, etc.), are accompanied by tension in the muscles of the anterior abdominal wall and, as a result, a significant increase in intra-abdominal pressure. IN normal conditions it is leveled out by the same intense closure of the diaphragmatic legs. The importance of the lower esophageal sphincter is small. Naturally, in a patient with a hernia, this kind of change in body position will inevitably lead to the reflux of gastric contents into the esophagus.

The increase in intra-abdominal pressure in the case of severe compression of the abdomen with relaxed muscles (for example, wearing tightly tightened corsets) is compensated mainly by tonic contraction of the lower esophageal sphincter. Violation of the obturator mechanism of the latter in this case can cause the same gastroesophageal reflux.

A similar casting mechanism takes place in a horizontal position or with the lowered top part torso.

In addition, there are a significant number of diseases and pathological conditions accompanied by increased intragastric pressure. This is hypermotor dyskinesia of the stomach as part of various gastroenterological pathologies (peptic ulcer of the stomach and duodenum, pylorospasm, pyloric stenosis, compression of the celiac trunk, etc.), overeating, excessive intake of carbonated soft drinks and many others. The mechanism of intragastric contents entering the esophagus can be explained by the “injection effect” that occurs as a result of significant motor activity of the stomach. In this case, the main compensatory barrier is also the cardiac sphincter, the reserve capabilities of which are significantly reduced due to the hernia of the abdominal cavity.

It goes without saying that gastroesophageal reflux does not occur due to any one of the factors listed above, but as a result of a common combination of them. Nevertheless, highlighting these predisposing aspects has, in our opinion, a certain practical interest. After all, even without knowing the true cause of gastroesophageal reflux, the doctor, with the help of appropriate recommendations to the patient, can help eliminate, if not all at once, then at least some of the listed factors that provoke reflux. And this, in turn, should lead to a reduction in the symptoms of the disease and the prevention of its complications.

It is also worth dwelling on the role of some other valves that ensure adequate closure of the cardia. The importance of the rosette of the mucous membrane of the distal segment of the esophagus in this regard is extremely high. The rigidity of the folds of the mucous membrane as a result of, for example, an inflammatory process does not allow them to close as tightly as is the case in an intact esophagus. Atrophy of the mucous membrane of the esophagogastric junction can also lead to cardia insufficiency. The importance of the so-called angle of His in ensuring the obturator function of the cardia is beyond doubt and is taken into account by surgeons in their practical activities when performing certain types of operations.

The concept of complex dynamic closure of the cardia reveals the physiological mechanism for preventing gastroesophageal reflux in some natural and pathological conditions, and also points to those conditions that disrupt this mechanism in hernias of the abdominal cavity. Information of this kind serves as the theoretical foundation underlying rational pharmacotherapy of cardin deficiency in all its manifestations (reflux esophagitis, peptic ulcers and peptic strictures of the esophagus).

Symptoms of Hiatal Hernia (HH)

Clinical picture of hernias POD is extremely polymorphic and depends not only on the type of hernia and its size. The external manifestations of these hernias are significantly modified by their frequent complications. A wide variety of diseases and pathological conditions, against the background, and sometimes due to which a diaphragmatic hernia occurs, give its symptoms an even more varied character.

For the convenience of presenting the semiology of this disease, the following clinical forms are distinguished:

• asymptomatic hernias;
• POD hernia with cardia insufficiency syndrome;
• PAD hernias without cardia failure syndrome;
• hernia of the pancreas in combination with other diseases of the gastrointestinal tract;
• paraesophageal hernia;
• congenital short esophagus.

The immanent logic of such a division is quite simple. Since a hernia of the PAD in most cases does not have “its own” clinical picture, in diagnostic terms the significance of such a symptom complex, the manifestation of which such a hernia can be, is extremely great. Below are situations in which you should actively look for this disease every time. The separation of paraesophageal hernias and congenital short esophagus into separate groups also has its own reason. The former are often disadvantaged, the latter are extremely difficult to diagnose.

• Asymptomatic hernias

According to different authors, there are no manifestations of asymptomatic hernias in 5-40% of cases. This increase in the percentage of detection of diaphragmatic hernias as accidental findings is due to several factors, primarily the improvement of diagnostic equipment and diagnostic techniques, as well as the greater focus of the modern practitioner in relation to this pathology.

An asymptomatic course is characteristic mainly of cardiac or esophageal hernias, i.e., small hernias. A thorough analysis of such cases did not reveal signs of cardia failure and reflux esophagitis.

• Hernias with cardia insufficiency syndrome

These or other signs of cardia insufficiency occur in 87.2-88.0% of cases of all hernias.

One of the most common symptoms of axial hernias is heartburn. It is observed after eating, with a sudden change in body position. At night, heartburn occurs more often, which is explained by increased tone vagus nerve(“vagal kingdom”) and, as a consequence, some relaxation of the lower esophageal sphincter.

The intensity of heartburn can vary significantly. Some patients suffer from it in such mild degree that they get used to it or adapt by taking any antacids for a long time (most often sodium bicarbonate or milk). For other patients, heartburn sometimes causes real suffering, and sometimes even makes them unable to work. We have often observed patients in whom a burning sensation behind the sternum was a kind of “occupational disease” (for example, in people with predominantly mental work, forced to spend a significant part of their working time at a desk, etc.).

In the origin of heartburn, of no small importance is the hypersensitivity of the inflamed mucous membrane of the esophagus to various irritants, the acid-peptic factor of gastric juice, stretching of the esophagus by a wave of gastroesophageal reflux, throwing of duodenal contents (primarily bile) into the esophagus, etc. In general, the intensity of heartburn is determined by on the one hand, the degree of “aggressiveness” of the listed factors, and on the other hand, the organ’s ability to self-cleanse (“esophageal clearance”).

The second most common, but perhaps the first most “colorful” symptom of hernia is pain. According to various authors, it is observed in 43.9-45.5% of cases. It should be noted, however, that not all patients can reliably identify their sensations, i.e. sometimes they confuse retrosternal pain of a burning nature with heartburn. The peculiarity of such pain is that they occur in approximately the same situations in which heartburn appears (when changing body position). Retrosternal pain appears and intensifies when the body is horizontal or tilted forward. These sensations are accompanied by regurgitation of gastric contents (“lace symptom”). They can be relieved either by changing the body position to horizontal or by taking alkalis.

All of the above suggests that, apparently, there is no sharp boundary between heartburn and burning retrosternal pain (provided that the latter occurs strictly under certain conditions and is not a sign of any other disease, for example, coronary heart disease). . Starting as heartburn, the unpleasant sensations can grow, intensify and finally turn into pain.

Pseudocoronary pain (localized in the heart area, has a “typical” irradiation, relieved by sublingual administration of nitroglycerin within just a few minutes) was noted in 10.4-25.0% of such patients. Often, the anamnesis also reveals a certain relationship between the occurrence of this symptom and food intake or a change in body position. Its “esophageal” genesis is supported by the absence of characteristic electrocardiographic changes, including various stress tests (bicycle ergometry, Master’s test, etc.), as well as other clinical signs of chronic coronary insufficiency. If there are additional symptoms of reflux esophagitis, then the cause of such pain is unlikely to be in doubt.

However, there are often situations in which a hernia of the PAD is combined with true coronary heart disease, especially since both of them often occur in old age. In this case, install correct diagnosis allows only the use of the entire extensive arsenal of modern medicine.

It should also be noted that a hernia of the POD itself can cause coronary pain when irritation of the vagus nerve gives rise to a viscero-visceral reflex followed by spasm of the coronary vessels of the heart. Such pain is so severe, and the situation is so tragic, that it can result in the development of myocardial infarction. This implies the need for a thoughtful attitude when clinical analysis causes of pain in each case of hernia of the ventricular hernia, especially in elderly and senile people

Differential diagnosis of coronary and esophageal pain is helped by the use of esophagomanometry and provocative tests with perfusion of the esophagus with a weak solution of hydrochloric acid (Bernstein test) and inflating a rubber balloon in it. Registration of large amplitude spastic waves on the esophagotonogram at the time of the onset of a characteristic attack of chest pain serves as convincing evidence in favor of their esophageal genesis. However, such coincidences do not occur so often in medical practice, even if provocative tests are carried out methodically correctly.

Thus, at least three factors occupy the leading place in the origin of chest pain in patients with hernias: peptic aggression from the gastric or duodenal contents, esophageal hypermotor dyskinesia and stretching of the esophageal walls with gastroesophageal reflux. Depending on the uniqueness of the situation, one or the other of these three factors may come to the fore. Pressing, squeezing pain behind the sternum radiating to the neck, lower jaw there is a consequence predominantly of esophagospasm, especially if they are accompanied by paroxysmal dysphagia. Pain when overeating, bloating, bending the body forward or in a horizontal position is mainly caused by reflux, i.e. peptic factor and esophageal dyskinesia.

In principle, there is another possible mechanism for the occurrence of retrosternal pain with hernias of the substernal area. It is described by surgeons who believe that large fixed hernias can cause compression of the branches of the vagus nerve in the POD or their strong tension due to upward displacement of the cardia and hernial sac. Clinically this manifests itself as pain. In addition, in such cases, some signs of disturbances in the functioning of the heart can sometimes be observed - various arrhythmias in combination with hypodiastole phenomena (episodes of brady- or tachycardia, syncope and collaptoid reactions). This symptom complex is designated as epiphrenal syndrome; it was first described by Bergman. In some patients with POD hernias, epiphrenic syndrome occurred at night or shortly after eating. Thus, not only a neurogenic factor (mechanical irritation of the branches of the vagus nerve), but also gastroesophageal reflux may play a certain role in its genesis.

In addition to complaints of substernal pain, patients with hernias of the substernal area may complain of pain in other localizations. These are the epigastric and interscapular regions, the Soffar-Minkowski zone and some others. Epigastralgia and pain in the hepatopancrea-atoduodenal zone, among other things, are caused by strangulation of hernias of the PAD and solaritis, accompanying gastric and duodenal ulcers, cholecystopancreatitis, etc. Unpleasant sensations and pain in the interscapular area caused by esophagospasm phenomena can be wired. It should be recalled that the Zakharyin-Ged zones corresponding to the esophagus are located precisely here, in the interscapular region.

Regurgitation occurs with gastric contents or air. In this case, it is usually preceded by a feeling of fullness in the epigastric region, which is a sign of aerophagia. This condition occurs soon after eating or while talking and causes such patients real suffering. Taking antispasmodics or analgesics is most often ineffective. The desired relief is brought only by belching a significant amount of air, so some patients induce it artificially. Sometimes epigastric or retrosternal pain may occur following regurgitation of gastric contents. varying intensity, which can be relieved by taking antacids.

The severity of belching is significantly influenced by the type of hernia. For example, in people with a fixed cardiofundal hernia, there is a significantly greater severity of this symptom than in patients with a fixed cardiac or non-fixed cardiofundal hernia. In the origin of the symptom, pylorospasm, antiperistalsis and increased gastric tone play a certain role, leading to an increase in intragastric pressure.

So-called intractable belchings, even within the “framework” of hernias, require careful differentiation for their hysterical genesis.

Regurgitation is observed in 36.8-37.0% of cases. It usually occurs after eating, as well as in a horizontal position or when bending the body forward. In terms of their composition, regurgitated masses represent food taken the day before or an acidic liquid, the volume of which in some cases can be very significant (“esophageal vomiting”). Such patients, when planning their stay in public or other places, try to carry with them special containers for regurgitation. Nocturnal regurgitation of significant volume can lead to the development of aspiration pneumonia. Regurgitation is a symptom mainly of cardiofundic and cardiac hernias of the heart. For esophageal and subtotal-gastric hernias, such a sign is uncommon. In other words, only “medium” sized hernias are accompanied by regurgitation. Small or large hernias usually do not appear UNDER the present symptom. This pattern has not yet found its explanation.

Vomiting is not preceded by nausea. With it, stomach contractions are usually not recorded. Food is expelled from the esophagus into the mouth due to its own contractions, and when the position of the body changes, it is poured out under the influence of gravity.

A type of regurgitation is rumination: the regurgitated contents enter the oral cavity, where they are chewed (often unconsciously), and then swallowed again. This phenomenon occurs infrequently.

Difficulties in passing food through the esophagus (dysphagia) are observed in 7-40% of patients with hernias of the esophagus. According to the last cited authors, dysphagia in such cases requires constant oncological vigilance. In patients with uncomplicated diaphragmatic hernias, disturbances in esophageal transit are intermittent and are observed when consuming liquid or semi-liquid foods. Solid food goes a little better (paradoxical dysphagia, or Lichtenstern sign). Dysphagia in such patients is provoked by taking cold or, on the contrary, very hot water (i.e., it depends on the temperature of the food), as well as hasty eating or neurogenic factors. Violation of the esophageal passage of this kind is a consequence of hypermotor dyskinesia of the esophagus (esophagospasm). However, dysphagia with hernias of the pancreas can be caused by some other reasons, which leaves a certain imprint on its clinical manifestations. For example, atony thoracic esophagus causes disruption of the esophageal passage mainly in the patient's supine position, when the influence of the gravity factor is neutralized. The addition of certain complications (strangulated hernia, development of peptic ulcer or stricture of the esophagus) gives dysphagia an “organic” character: from intermittent and paradoxical dysphagia turns into persistent and occurs when eating “dense” and dry foods. It is facilitated by fluid intake, but differs from that with achalasia cardia in that strictures of the esophagus, as a rule, do not give a symptom of mechanical opening of the cardia under the influence of a column of liquid food accumulated in this organ (a feeling of “sinking”). Sublingual nitrates do not provide relief.

Sometimes esophageal transit disorders are accompanied by severe chest pain (dysphagia dolorosa). These pains occur in cases where hernias of the POD are complicated by the development of severe reflux esophagitis. Disruption of esophageal passage in such patients, in addition to esophageal dyskinesia, is caused by inflammation and swelling of the mucous membrane of the esophagus (a kind of “obstruction” of the esophagus). As esophagitis is treated, pain and dysphagia decrease.

Cardiac and cardiofundal hernias of the POD are often accompanied by the symptom described above.

Hiccups are observed in 3.3% of patients with axial hernias. Its distinctive feature is long duration and connection with food. The authors point out that hiccups can last for weeks and months, with virtually no cure. In its genesis, according to many clinicians, inflammation of the diaphragm (diaphragmatitis) and irritation of the phrenic nerve by the hernial sac are important. The same authors identified glossalgia (glossodynia - burning of the tongue) with approximately the same frequency as hiccups. The origin of the present symptom is unknown. However, we can assume the following: if a burning tongue is accompanied by hoarseness, and there are also signs of reflux esophagitis, then a similar clinical picture may be caused by the throwing of gastric or duodenal contents into the oral cavity and larynx (“peptic burn”). In addition, in the pathogenesis of glossalgia, the condition of the oral cavity, the presence metal crowns on teeth, vitamin deficiencies, food allergies, etc.

Thus, the clinical picture of hernias in combination with cardia insufficiency is essentially a manifestation of reflux esophagitis and is determined by the condition of the esophageal mucosa. In addition, the symptoms of hernias also depend on their size.

• Hernias without cardia failure syndrome

In 12% of cases of axial hernia, there are no clinical or instrumental signs of lower esophageal sphincter insufficiency.

The clinical picture of hernias without cardioesophageal insufficiency syndrome is determined mainly by the phenomena of esophageal hypermotor dyskinesia or complications of the underlying disease. Retrosternal, precordial or epigastric pain prevails, occurring immediately after eating, when lifting heavy objects or excitement. They last from several minutes to several days. The pain is well relieved by taking non-narcotic analgesics or nitroglycerin under the tongue, but is not relieved by validol. Relief comes from changing the body position from vertical to horizontal, as well as drinking water or other liquid. In some cases, to reduce pain, such patients resort to eating. Apparently, the latter leads to the activation of the esophageal pacemaker, the impulse from which extinguishes the centers of second-order automaticity.

Dysphagia of a paradoxical or intermittent type can often be noted.

The nature of the pain changes if it is caused by compression of the hernial sac in the pod, perivisceritis, solaritis, i.e., the addition of complications. Solaritis is characterized by persistent epigastralgia, which intensifies with pressure on the projection zone solar plexus and weakening in a position on all fours or when bending the body forward. Eating does not have much effect on them, except in cases of overeating. Perivisceritis manifests itself as dull, aching pain high in the epigastrium or at the xiphoid process of the sternum. Often one can note a positive Mendelian sign and low-grade fever. When the hernial sac is compressed in the hernial orifice, patients complain of constant, dull, less often piercing pain in the epigastric region and behind the sternum, radiating to the interscapular area.

Over time, if appropriate preventive recommendations aimed at preventing an increase in the size of the hernia are not followed, the obturator function of the cardia may be impaired. Symptoms of reflux esophagitis appear.

• Hernias in combination with other diseases of the gastrointestinal tract

In 34.9% of cases, hernias of the pancreas are accompanied by various gastroenterological diseases. These are peptic ulcers of the stomach and duodenum, chronic gastroduodenitis, chronic cholecystitis (including calculous), pancreatitis, intestinal diverticulosis, etc.

Such situations inevitably pose extremely important questions to the practicing physician regarding the cause-and-effect relationship between hernias of the PAD and the listed diseases, as well as therapeutic tactics. The results of the analysis indicate that the first place among these diseases is occupied by duodenal ulcer. Stomach ulcers are somewhat less common. It is believed that in young people, a hernia of the pancreas does not simply accompany a duodenal ulcer, but is, as it were, a complication of the latter. Such patients begin to present complaints that significantly modify the “usual” clinical picture of the pre-existing disease. Epigastralgia loses its characteristic time dependence on food intake: it occurs during eating and when changing body position from vertical to horizontal. Signs of cardioesophageal insufficiency (dysphagia, regurgitation, belching, heartburn, retrosternal pain, etc.) appear or sharply intensify, increasing in the supine position and when the body bends forward.

Chronic cholecystitis and chronic pancreatitis may also have a pathogenetic connection with hernias of the pancreas. Severe disturbances in the motor function of the esophagus, accompanied by contraction of the longitudinal muscles, can provoke traction of the cardia into the chest cavity. On the other hand, a pre-existing hernia of the PAD can cause a viscero-visceral reflex to the biliary tract and, as a consequence, their dyskinesia. Finally, there is no need to say that both of these diseases can potentiate each other.

The impact of a diaphragmatic hernia on the exocrine function of the pancreas also makes sense to be considered from a similar perspective. In this case, the hernia causes a more or less persistent spasm of the sphincter of the hepatopancreatic ampulla, which is accompanied by a violation of the outflow of secretions and damage to the parenchyma of the organ.

In conclusion, we should once again recall one extremely important, in our opinion, position: all persons with various gastroenterological diseases should be subjected to a thorough, qualified examination for the active detection of hernias.

• Paraesophageal hernias

As mentioned, paraesophageal hernias account for 0.4-1.4% of cases of all hernias.

Basically, they do not give external manifestations and are diagnosed accidentally as a result of an examination conducted for some other reason. However, if such hernias reach a significant size and, as a result, cause esophageal compression in the POD, then dysphagia begins to appear in patients. The latter has the features of “organic”, i.e. constant dysphagia, aggravated by the consumption of dense and dry food and difficult to treat with antispasmodics. Only in isolated cases do paraesophageal hernias cause symptoms of esophagospasm in all its varieties.

When paraesophageal hernias are strangulated, pain begins to prevail in their clinical picture, the epicenter of which is usually localized behind the sternum or in the epigastrium. The intensity and irradiation of pain can be very different depending on the condition of the strangulated organ and what part of the gastrointestinal tract is blocked in the hernial orifice. The substrate of paraesophageal hernias can be the bottom and antrum stomach, part of the small or large intestine, lesser omentum. Gastrointestinal hernias have been described.

The phenomena of cardia insufficiency for paraesophageal hernias are uncommon. The exception is the combination of axial and paraesophageal hernia, when the significant size of the latter causes prolapse of the cardia into the chest cavity.

• Congenital short esophagus

The general name "congenital short esophagus" often describes two completely different anomalies. The first includes the so-called thoracic stomach, which also exists in two forms: a) the cardiac part of the stomach is located in the chest; b) the entire stomach has intrathoracic localization. The hernial sac as such is absent in both cases. This developmental anomaly was described by Harrington. In the second type, the esophagus in the distal part contains the gastric mucosa. The muscular wall and serous membrane have a normal structure (“shortened esophagus with gastric mucosa,” according to English-speaking authors).

The symptoms of such conditions are difficult to distinguish from the clinical picture of axial hernias of the pancreas with cardio-esophageal insufficiency syndrome. Only anamnesis data indicate the congenital nature of the disease. As a rule, a true diagnosis is established only through surgery or even as a result of an autopsy.

Diagnosis of hiatal hernia (HH)

A study of the motor function of the esophagus, in our opinion, should be carried out in every patient with hernia of the esophagus. Esophagomanometry allows, firstly, to directly diagnose this disease; secondly, to establish the nature and severity of concomitant esophageal dyskinesias; thirdly, in some cases, to objectively assess the effectiveness of conservative treatment.

When recording the motor activity of the esophagus using the balloon method, it is necessary to determine the state of the pharyngoesophageal and cardiac sphincter (their tone, the ability to relax when swallowing, the width of the corresponding “zones”), as well as the thoracic esophagus on various levels(amplitude, duration and shape of contraction waves and their nature - peristaltic or spastic).

The manometric picture of axial hernias is characterized by expansion of the lower zone high blood pressure above the diaphragm. At the same time, it is methodologically very important to correctly determine the level of the location of the POD, since it serves as a guide. Its localization is established by changing the direction of the tops of the respiratory waves from positive to negative - the so-called reversion of respiratory waves. A reliable manometric sign of axial hernias is the displacement of the lower zone of increased pressure proximal to the POD.

Cardiofundal and subtotal-gastric, i.e., diaphragmatic, hernias of significant size have two zones of increased pressure. The first zone is formed when the balloon passes through the POD and indicates the degree of compression of the hernial sac in it. The second zone corresponds to the location of the proximally displaced lower esophageal sphincter. The size of the hernia, more precisely the length of the hernial sac, can be judged by the distance between these two areas.

Esophagomanometry is an extremely accurate diagnostic method, which sometimes makes it possible to detect even “X-ray-negative” hernias of the abdominal cavity, as well as to determine the degree of reliability of the obturator mechanism of the cardia (tone of the lower esophageal sphincter, consistency of the diaphragmatic crura). In some cases, it is even possible to record gastroesophageal reflux, which is graphically displayed as an additional wave of small amplitude.

Paraesophageal hernias are not diagnosed manometrically.

• Differential diagnosis

According to Harrington's figurative expression, hernias of the lower abdomen, due to the diversity of their clinical picture, are a “masquerade of the upper abdomen.” The variety of symptoms, the abundance of complications and the very frequent combination with other gastroenterological diseases are the objective reasons that cause errors and difficulties in diagnosing hernias. However, one cannot ignore the insufficient familiarity of practical doctors with the clinical picture of the present disease. In our opinion, an active search for hernias in each patient with gastroenterological pathology will allow us to avoid a significant number of diagnostic errors. This rule must be observed not only if there is the slightest suspicion of a hernia, but also in the absence of any external manifestations. As is known, asymptomatic this disease is observed in 5-40% of cases. It is precisely situations like this that pose the greatest difficulties for recognizing hernias. In respect of differential diagnosis in this case, first of all, one should keep in mind the so-called ampulla of the esophagus, which is radiologically difficult to distinguish from a small axial hernia.

The ampulla of the esophagus is a phase state of its motor function and is detected in many practically healthy individuals, usually after 40-50 years. Any external signs of this condition are almost always absent, but radiologically one can detect a variable expansion of the supradiaphragmatic portion of the esophagus, which forms during inspiration and when holding the breath in a horizontal position. During the exhalation phase it usually disappears. Its shape is round or pear-shaped, the upper and lower borders are pointed, the size is about 3-4 cm, the contours are clear and even. The folds of the mucous membrane of the esophagus, passing through the ampulla, are defined in it in the form of thin longitudinal stripes, which extend further to its abdominal section.

When carrying out a differential diagnosis between the esophageal ampulla and an axial hernia, it should be borne in mind that the hernia of the esophagus is characterized by a persistent retention of a radiopaque suspension of hemispherical, semi-oval or cylindrical shape above the diaphragm. Inside the axial hernia, folds of the gastric mucosa are determined. Its dimensions usually exceed 3-4 cm and, as a rule, do not depend on the act of breathing, but are determined, among other things, by the degree of filling it with a suspension of barium sulfate or air.

The lower contours of the hernial sac directly pass into the subdiaphragmatic part of the stomach, so it is quite difficult to visualize them.

The presence of a hernia has a certain impact on the process of formation of the ampoule itself. Disorders of esophageal motility as part of this disease can level its size and slightly change its shape. Due to longitudinal shortening of the esophagus caused by an axial hernia, the ampulla is dystopic upward. There, its proximal border is defined in the form of the so-called Hacker sphincter (horizontal constriction). In its distal part, the ampulla first directly passes into the contours of the hernial sac and only then, at the final stage of esophageal transit, partitions begin to form between it and the diaphragmatic hernia, which are called Satsky rings, ring-shaped notches, etc. These rings are essentially x-ray ь image of the anatomical cardia shifted upward.

The transition of the radiopaque mass through the cardia in healthy individuals and patients with hernias of the pancreas is carried out differently and can be conditionally divided into 5 stages:

• the esophagus is filled with a suspension of barium sulfate, which for some time lingers at the level of 1.5 cm near the diaphragm, the esophagus and stomach are separated from each other by the supradiaphragmatic zone of the cardiac sphincter;
• the radiopaque mass moves lower, but again temporarily stops at the level of the diaphragm, now the esophagus and stomach are “separated” by the abdominal part of the esophagus;
• the abdominal segment of the esophagus is filled and appears on radiographs as a narrow tube 2-3 cm long, above it an “ampullary-like expansion” is visible, the proximal border of which looks like a “circular notch”;
• the “circular notch” disappears, the abdominal segment of the esophagus expands even more;
• in phase take a deep breath the abdominal segment of the esophagus, corresponding to the zone of the cardiac sphincter, is compressed in the diaphragmatic opening, until the next peristaltic wave appears between the esophagus and the stomach, an ampulla is determined,

The described process occurs in healthy individuals. Small hernias POD changes it as follows:

• after swallowing a suspension of barium sulfate, not one, as normal, but two sections of the esophagus remain unfilled; the first - at the level of 1.5 cm above the prolapsed part of the stomach - corresponds to the supradiaphragmatic part of the lower esophageal sphincter or ampulla of the esophagus; the second - at the level of the diaphragm - occurs due to compression of the hernial sac by its legs;
• a suspension of barium sulfate passes through the zone of the cardioesophageal junction;
• between the body of the esophagus and the subdiaphragmatic part of the stomach, a “circular notch”, an “ampulle-like expansion”, the lower esophageal sphincter and, finally, the hernial protrusion itself are successively determined;
• the peristaltic wave expels the radiopaque mass from the thoracic esophagus, only the esophageal ampulla and hernial protrusion are visible;
• the peristaltic wave pushes the barium sulfate suspension out of the ampoule, the latter disappears; Only a hernia of the pod is clearly detected.

So detailed description the process of the radiopaque mass passing through the area of ​​the esophagogastric junction should, in our opinion, help resolve the difficulties that can sometimes arise during the differential diagnosis of the esophageal ampulla from hernias. A well-performed study of the motor function of the esophagus (esophagomanometry) can provide even greater help. A hernia of the diaphragm is manometrically characterized by the appearance on the curve of not one, but two zones of increased pressure (the first at the level of the crura of the diaphragm, the second at the level of the cardiac sphincter), reversal of the respiratory teeth and a decrease in the distance from the anterior incisors to the cardia. In healthy people, the esophagotonogram is normal.

Sometimes hernias of significant size have to be differentiated from relaxation, or paralysis, of the diaphragm. Relaxation of the diaphragm is characterized by a decrease in the resistance of the thoraco-abdominal obstruction, as a result of which the abdominal organs move into the chest cavity. According to its origin, it can be congenital (hypoplasia) or acquired (diaphragmatitis of various etiologies, lesions of the phrenic nerve). Morphologically, right- and left-sided relaxation is distinguished, which in turn are divided into complete and limited (partial). Elevation, or high standing of the diaphragm, should not be confused with this disease.

With hernias of the abdominal cavity, it is most often necessary to differentiate the relaxation of the left dome of the diaphragm, since in such cases the hollow organs of the abdominal cavity (stomach and intestines) move upward. The stomach is significantly deformed and dystopic in such a way that its greater curvature is adjacent to the diaphragm, the cardia is displaced posteriorly, and the antrum is shifted to the left of the spine and anterior to the cardiac region. This creates a kind of bend in the organ, reminiscent of a cascading stomach.

For a long time it was believed that relaxation of the diaphragm has no characteristic clinical manifestations and is diagnosed only by chance during an X-ray examination. However, this opinion has been refuted. Such patients complain of a feeling of heaviness in the epigastrium after eating, dysphagia, belching, nausea, vomiting, heartburn, palpitations, shortness of breath and dry cough. X-ray signs of relaxation of the left dome of the diaphragm are a persistent increase in the level of its location: a smooth, continuous, arched line, convex upward, extending from the shadow of the heart to the left lateral wall of the chest. When breathing, the relaxed area of ​​the thoraco-abdominal obstruction can perform movements of a twofold nature: normal, like in all healthy individuals, as well as paradoxical - rising on inhalation and lowering on exhalation (Alyshevsky-Winbeck symptom). At the same time, the healthy right dome of the diaphragm shifts to the opposite side (yoke sign, or Wellman sign). In both cases, the amplitude of respiratory movements is limited.

The lower pulmonary field is usually darkened. Sometimes you can detect a shift of the heart shadow to the right, i.e., to the healthy side. Immediately below the diaphragm are the gas bladder of the stomach and the splenic flexure of the colon. It is fundamentally important that the contours of these organs do not extend into the chest cavity.

To clarify the syntopy of the stomach and colon with the diaphragm, it is advisable to conduct an X-ray contrast study, as a result of which, in all cases of relaxation of the colon, it is possible to detect the movement of these organs (usually the stomach) into the chest (but not into the chest cavity). In this case, the esophagus, being firmly fixed in the POD, turns out to be curved to the left and upward.

Contrasting the colon with a barium sulfate suspension demonstrates that splenic angle located in the contour of the chest just below the diaphragm and contains a significant amount of gas.

The fundamental difference between relaxation of the thoraco-abdominal barrier and a hernia of the abdominal cavity is the absence in the first case of the symptom of a hernial orifice, i.e., depressions, retractions and other kinks in the contour of the stomach or colon. A hernia is characterized by a change in the level and shape of the diaphragm with varying degrees of filling of these organs. In cases that are particularly difficult for differential diagnosis, it is advisable to apply pneumoperitoneum: in patients with relaxation, gas does not penetrate into the chest cavity through the POD, but is located in the form of a thin crescent-shaped strip under the diaphragm. Esophagomanometry can provide significant assistance in this regard. A decrease in the distance from the anterior incisors to the cardia, reversal of the respiratory teeth and the two-humped nature of the curve are fairly reliable manometric signs of a hernia of the lower back.

Some symptoms of hernias, such as chest pain, must be distinguished from the manifestations of angina pectoris and myocardial infarction. As already mentioned, retrosternal pain is a consequence of inflammation and ulceration of the mucous membrane of the esophagus, as well as a violation of its motor function. However, in elderly people, hernias of the POD can sometimes cause angina pectoris or even myocardial infarction as a pathological viscero-visceral reflex. Finally, a hernia of the PAD is sometimes simply combined with coronary heart disease. Thus, in each specific case it is necessary to solve a very complex differential diagnostic task - to determine the cause of retrosternal pain. Its solution should begin with a thorough history taking: the occurrence of pain after eating and in a horizontal position indirectly indicates the presence of a hernia. However, this sign is not reliable enough, since sometimes true angina develops after eating (a kind of angina pectoris). A completely reliable verification method coronary disease heart tests are repeated electrocardiography at rest and various stress and drug tests (Master's step test, bicycle ergometry, test with nitroglycerin, etc.). On the other hand, if after adequate treatment of peptic esophagitis the frequency of pain attacks and their intensity have decreased significantly, then in retrospect we can confidently assume the esophageal genesis of the pain symptom.

Of particular value is a functional provocative test with inflation of a balloon inserted into the esophagus or perfusion of the esophagus with a 0.1 N solution of hydrochloric acid (Bernstein test). In this case, depending on the purpose, either an esophagotonogram or an electrocardiogram can be recorded. The diagnosis of the disease is established based on the results obtained.

Prolonged and severe retrosternal pain in persons with hernias of the abdominal cavity always requires the exclusion of myocardial infarction. The latter is supported by the phenomena of increasing cardiovascular failure (general weakness, frequent thread-like pulse, drop in blood pressure, pale skin, etc.) Characteristic changes in the electrocardiogram, increased activity of aminotransferases and creatine phosphokinase, leukocytosis, increased ESR, increased body temperature, the presence zones of myocardial hypo- and akinesia during echocardiography.

In some cases, difficulties arise in determining the nature of inflammatory lesions of the esophageal mucosa during hernias of the esophagus. In principle, their combination with esophagitis of any etiology (infection, trauma, burn) is quite acceptable, therefore it is necessary to establish whether a patient with a hernia of the POD has cardial insufficiency and whether there is a pathogenetic connection between it and esophagitis. To do this, based on an analysis of complaints, anamnesis data and the results of radiography of the esophagus, esophagomanometry and pH-metry, it is necessary to make a conclusion about the presence of reflux.

The combination of an axial hernia with an ulcer of the distal esophagus requires solutions to the same issues. In addition to the acid-peptic factor, tuberculosis, syphilis, disintegrating tumor (cancer) and some others can act as etiological factors for ulceration of the esophagus. The diagnosis in this case is verified by radiography of the esophagus, esophagomanometry, pH-metry, immunological, bacteriological and histological studies.

The presence of peptic stricture of the esophagus in patients with hernias of the esophagus requires the exclusion of stenoses of other etiologies (tumor, burn, etc.) or compression from the outside that are increased in size neighboring organs.

Treatment of hiatal hernia (HH)

A radical way to correct hernias is surgical intervention, which in a certain percentage of cases allows to achieve permanent elimination of the hernia. Conservative treatment measures have slightly different goals. The effectiveness of treatment and its nature largely depend on how much the features of the course of the disease are taken into account, in other words, which symptom complex comes to the fore in a particular case: reflux esophagitis, hypermotor dyskinesia of the esophagus, peptic ulcer or stricture of the esophagus, manifestations of other gastroenterological diseases .

Since the clinical picture of hernias in the vast majority of cases is determined by the symptoms of gastroesophageal reflux, the therapist’s main efforts should be directed toward its elimination. The treatment of reflux esophagitis is described in detail in section 9.3.6; this section discusses only general issues.

• Conservative treatment

Treatment should begin with conservative measures, surgery must be carried out strictly according to specific indications (primarily complicated forms of hernias and the failure of previous drug therapy).

Conservative treatment Patients who apply for the first time should be carried out in an inpatient setting, where a qualified examination is much easier to carry out than in a clinic. Upon completion of the main course of treatment, all patients with hernias of the ventricular hernia must be registered with a dispensary. The main objectives of the latter are prevention, timely diagnosis and correction of relapses of inflammatory lesions of the esophageal mucosa, as well as the prevention of complications. Clinical examination can be carried out on an outpatient basis, but at least 2 times a year. If relapses of esophagitis are detected, a second course of pharmacotherapy can be started outside the hospital; the patient is hospitalized only if such treatment is ineffective.

Treatment of patients with axial hernia, complicated by peptic ulcer of the esophagus, is currently insufficiently developed, despite the abundance of pharmacological drugs. This condition serves as a direct indication for surgery in a significant percentage of cases. However, in some situations (advanced age of patients, concomitant severe diseases, patient’s refusal to undergo surgery, etc.), preference should be given to pharmacotherapy. General principles the latter are similar to those for reflux esophagitis, but the tactics have their own characteristics. Treatment of a peptic ulcer of the esophagus “within the framework” of the red POD should be more intense and lengthy, requiring discipline from the patient and perseverance on the part of the doctor. All this is due to the fact that due to the peculiarities of the pathogenesis of ulcers (the constant effect of gastric juice and kelci on the mucous membrane of the esophagus in general and on the ulcerated area in particular), the influence of damaging factors usually prevails over the influence of protective factors. Therapy for such patients often drags on for months. The duration of remission largely depends on the implementation of certain doctor’s recommendations and the timeliness of medical examination.

The presence of scar-inflammatory shortening or stenosis of the gullet also introduces its own characteristics into therapeutic tactics. With a certain degree of confidence, it can be stated that severe morphological changes in the mucous membrane of the esophagus in this case are due to the untimely diagnosis of cardioesophageal insufficiency. Due to the particular severity of inflammation of the mucous membrane of the esophagus during its shortening or stenosis, the use of long-acting antacids and flattering anti-inflammatory drugs comes first in drug therapy. Such patients must be hospitalized. The course of treatment in a hospital lasts at least 1-2 months. If necessary, pharmacotherapy can be continued on an outpatient basis. Its main task is the immediate and complete elimination of all symptoms of esophagitis and scarring of peptic ulcers. Only this gives at least some reason to believe that the process of shortening or stenosis of the esophagus will stop. If the narrowing of the organ is severe, then conservative treatment serves as preoperative preparation, after which patients should be sent to specialized surgical hospitals for surgical correction or bougienage. It should be emphasized that for safety reasons it is not recommended to carry out bougienage in a therapeutic clinic or on an outpatient basis.

It is advisable to refer patients with an axial hernia complicated by shortening of the gullet for surgical treatment, since shortening prevents the hernial sac from being brought back into the abdominal cavity.

Treatment of patients with hernias of the abdominal cavity, complicated by the development of hypochromic iron deficiency anemia as a result of chronic blood loss, you should also start with the appointment of antacids and locally acting anti-inflammatory drugs. As mentioned above, the main mechanisms of occult bleeding in this situation are diapedesis of red blood cells through the loosened, inflammatory-altered mucous membrane of the esophagus, as well as its erosive and ulcerative lesions. At the same time, it is necessary to carry out anti-reflux measures. Otherwise, any, even the most massive anti-anemic and hemostatic therapy is unlikely to be particularly successful. Treatment should be carried out strictly in a hospital. Required preventive actions which are carried out at least 3-4 times a year.

Persons with hernias of the lower back and concomitant pernicious-like or hemolytic anemia after preliminary correction, it is advisable to send the latter to surgical hospitals in order to avoid relapses of anemia.

Combination of hernias with other gastroenterological diseases(peptic ulcer of the stomach and duodenum, chronic cholecystitis, chronic pancreatitis, etc.) requires identification of the “leading pathology,” the elimination of which significantly increases the effectiveness of treatment. For example, sometimes when a hernia of the lower back is combined with cholelithiasis, the latter is the “leading” pathology. In this case, cholecystectomy leads to clinical recovery. However, it is possible reverse situation when the symptom complex of a hernia of the PAD with cardioesophageal insufficiency and reflux esophagitis predominates. Cholelithiasis turns out to be a “second disease,” so cholecystectomy, naturally, does not give the desired results.

The tactics of conservative treatment of patients with paraesophageal hernias have been studied much less than the treatment of axial hernias. This is due to the fact that iaraesophageal hernias are quite rare. Many surgeons prefer surgical treatment of such patients. As the main argument in favor of this method, they cite the tendency of paraesophageal hernias to strangulate. Such tactics “are justified primarily in relation to young and middle-aged people.” In elderly patients with severe comorbidities, appropriate lifestyle and diet interventions can be recommended to reduce the risk of developing a strangulated hernia. This is limiting some exercise and heavy lifting to avoid straining the abdominal muscles, a restricted diet causing flatulence food products, adequate treatment chronic constipation and etc.

Prescribing antireflux therapy and antacid drugs to such patients does not make much sense, since paraesophageal hernias, as a rule, are not accompanied by reflux of gastric contents into the esophagus.

A one-time adequate course of complex treatment of patients with axial hernias is effective in 92% of cases. At the same time, excellent results are observed in 34%, good - in 42%, and slight improvement - in 16% of patients. The absence of any effect was noted in 8% of patients.

The ability to work of patients with hernias of the pancreas is limited. All types of work that involve lifting significant weights or bending the body forward are undesirable. In some cases, individuals who are forced to spend a significant portion of their time at a desk (this body position provokes gastroesophageal reflux) are advised to change jobs. It is advisable to transfer patients with severe peptic esophagitis or long-term non-scarring ulcers of the esophagus to the GG disability group.

• Surgery

Surgical intervention for hernias of the lower back is indicated when adequately repeated courses of drug treatment in a specialized hospital are unsuccessful, when treating large hernias accompanied by severe dysphagia or regurgitation in combination with aspiration pneumonia, when hernias are combined with peptic reflux esophagitis that is not amenable to conservative treatment measures, with frequent bleeding, peptic stricture of the esophagus.

Contraindications to surgical treatment of hernias include various serious concomitant diseases that can cause life-threatening complications in the postoperative period. When determining indications and contraindications for surgical treatment of hernias, one should proceed from the fact that the risk of surgical intervention does not exceed the risk of the underlying disease.

Of the large number of different methods of surgical treatment of sliding hernias, the most widespread are operations aimed at suturing the hernial orifice and strengthening the esophageal-diaphragmatic ligament (crurorrhaphy), fixing the stomach in the abdominal cavity (various options for gastropexy), restoring an acute angle of His, preventing or elimination of gastroesophageal reflux (fundoplication).

Suturing of the hernial orifice (legs of the diaphragm) is most often performed using the Allison technique. Access - left-sided thoractomy in the seventh or eighth intercostal space. After a wide dissection of the mediastinal pleura, the esophagus is isolated from the surrounding tissues to the level of the inferior pulmonary vein. With severe periesophagitis due to severe reflux esophagitis, there is a risk of damage to the vagus trunks, mediastinal pleura on the right and the thoracic duct. Therefore, manipulations at the stage of isolating the esophagus must be very delicate.

The mobilized esophagus is placed on a rubber or gauze holder. After this, the legs of the diaphragm are exposed and sutured together using 3-5 separate interrupted sutures using non-absorbable suture material.

Before tying the threads, a hole is made in the diaphragm at a distance of 3 cm from its esophageal opening. With fingers inserted into the abdominal cavity through the formed hole, the stretched esophageal-phrenic ligament, peritoneum and diaphragmatic pleura are protruded into the pleural cavity. The excess hernial sac formed by these tissues is excised. The remains of the esophageal-diaphragmatic ligament are fixed with separate sutures to the edge of the diaphragm at its esophageal opening. After this, the previously applied sutures are tied to the legs of the diaphragm. The newly formed esophageal opening of the diaphragm should allow the tip of the finger to pass through.

The disadvantage of the Allison operation and its various modifications is the relatively high rate of hernia recurrence (6-10%). In addition, this operation does not significantly affect the elimination of reflux esophagitis, which is observed in 20-25% of patients after this type of intervention. In this regard, crurorrhaphy according to the Allison technique is currently practically not used as an independent surgical intervention, but only in combination with other surgical procedures undertaken for sliding hernias of the infrathorax.

Among various options gastropexies most commonly use the Hill procedure. Access - upper median laparotomy. After mobilizing the left lobe of the liver and lowering the abdominal part of the esophagus into the abdominal cavity, the legs of the diaphragm are isolated, suturing them similarly to the Allison technique with separate interrupted sutures. Next, grasping the esophageal-diaphragmatic ligament, the anterior and posterior walls of the stomach near the place of attachment of the lesser omentum near the cardiac part, the stomach is fixed to the preaortic fascia, while trying not to damage the motor branches of the vagus nerve.

Operation Hill is quite effective in terms of curing a sliding hernia of the pancreas. Its effect on gastroesophageal reflux is much less pronounced. Therefore, at present this operation has limited use. It is mainly used for sliding hernias without concomitant reflux esophagitis.

Of the operations aimed at recreating an acute angle of His for the purpose of correcting or preventing gastroesophageal reflux in the treatment of hernias, the most commonly used are esophagophrenofundoplexy according to Lortat-Jakob or esophagophrenofundoplexy according to Latast. In the first type of operation, the fundus of the stomach is sutured to the left edge of the abdominal part of the esophagus; in the second type, in addition to this, the fundus of the stomach is sutured to the diaphragm using separate sutures. A necessary element of both types of operations is suturing of the POD. These operations are difficult to perform for large sliding hernias, and their effectiveness in preventing gastroesophageal reflux turned out to be low. Therefore, they are practically not used as independent methods for the treatment of hernias, although they are used as separate stages of more complex types surgical interventions.

Most widespread in surgical treatment of sliding hernias, especially in combination with reflux esophagitis, received fundoplication using the Nissen technique. The operation is performed from the abdominal approach (upper median laparotomy). After bringing down the proximal part of the stomach from the chest cavity, the abdominal part of the esophagus is mobilized along its entire length. The esophagus is taken on a holder, the hepatogastric ligament is dissected, and mobilized back surface upper third of the stomach. The next stage is stitching the legs of the diaphragm SH1YA to reduce the size of the POD. Then, the anterior and posterior walls of the upper stomach are sutured with separate seromuscular sutures, forming a “sleeve” around the abdominal part of the esophagus. The muscular membrane of the anterior wall of the esophagus is also picked up in the same sutures to avoid slipping of the formed cuff in the distal direction, which will inevitably lead to relapse of the disease. At the end of the operation, the anterior wall of the stomach is fixed to the anterior wall with separate sutures. abdominal wall, grasping the posterior plate of the vagina of the left rectus abdominis muscle in the suture. According to another modification, after fundoplication, the stomach is fixed with separate sutures to the preaortic fascia. With this method of surgical intervention, excellent and good results were obtained in 85-95% of patients.

With the long-term existence of a sliding hernia of the POD and concomitant peptic esophagitis, in approximately 5-10% of patients, secondary shortening of the esophagus occurs, which creates significant difficulties during surgical intervention when moving the proximal part of the stomach into the abdominal cavity. In these cases, the Nissen procedure is performed through the left transthoracic approach, leaving part of the stomach in the pleural cavity.

A fairly effective intervention in terms of curing diaphragmatic hernia and concomitant reflux esophagitis is Belsey operation. This operation is indicated for patients with large sliding hernias of the pod in combination with reflux esophagitis. Contraindications to its implementation are severe cardiopulmonary diseases, since thoracotomy is used as a surgical approach.

The incision is made along the seventh or eighth intercostal space on the left. After dissection of the mediastinal pleura, the esophagus and proximal stomach are widely mobilized, moving it through the dilated opening of the diaphragm into the pleural cavity. Provisional sutures are placed on the legs of the diaphragm using the Allison technique. Then U-shaped sutures are placed on the esophagus and anterolateral surfaces of the stomach, retreating 2 cm up and down from the esophagogastric junction. After tying this series of sutures, the anterior 2/3 of the circumference of the esophagus is invaginated into the lumen of the stomach. In this case, the acute angle of His is recreated. The second row of sutures begins at a distance of 1-1.5 cm from the first, and, in addition to the wall of the esophagus and stomach, the tendon center of the diaphragm is also sutured. When they are tied, the esophageal-gastric junction is immersed in the abdominal cavity, the cardiac part and the fundus of the stomach are tightly fixed to the diaphragm. The advantage of this operation is also the formation of the valve apparatus of the cardiac part. According to most surgeons, the Belsey operation more complicated operation Nissen, somewhat more often there is a recurrence of hernia and reflux esophagitis.

In our country, the main operation for sliding hernias of the underlying hernia, especially when combined with reflux esophagitis, is Nissen fundoplication, which gives quite satisfactory immediate and long-term results. Postoperative mortality usually does not exceed 1-2%. When a hernia of the pancreas is combined with duodenal ulcer, it is recommended to supplement fundoplication with selective proximal vagotomy, which can significantly reduce the acidity of gastric juice, cure the patient of the ulcer and minimize the possible phenomena of reflux esophagitis even after fundoplication. The Belsey operation is used much less frequently, and Hill gastropexy is used even more rarely.

The presence of paraesophageal hernia (if there are no serious contraindications from vital important organs) is an indication for surgical treatment due to the real possibility of developing severe complications, such as compression, infringement of prolapsed organs, up to their perforation, bleeding from the compressed part of the stomach. At large sizes paraesophageal hernia may compress the mediastinal organs (“compression syndrome”), which is also an indication for surgery.

In case of complicated paraesophageal hernias (strangulation, perforation, bleeding), the operation is usually performed from the abdominal approach, since the serious condition of the patients does not allow the intervention to be performed from the more traumatic transthoracic approach. In addition, abdominal access is more convenient for performing resection of a particular area of ​​the strangulated organ.

The main type of surgical intervention is suturing the hernial orifice after preliminary excision of the hernial sac (diverticulum-like protrusion of the peritoneum). For combined and large paraesophageal hernias, the operation is supplemented with Nissen fundoplication or Hill gastropexy. Recently, reports have appeared in the literature about the use of preserved dura mater and various synthetic materials for plastic surgery of extensive diaphragm defects.

As planned, if the general condition of the patients is satisfactory, the operation is performed through a transthoracic approach. The outcomes of surgical interventions in the absence of serious complications from strangulated organs are, as a rule, quite satisfactory. Recurrences of hernias are quite rare.

In conclusion, it should be noted that such a large number of surgical interventions proposed for the surgical treatment of hernias indicates the dissatisfaction of doctors with the results of these operations and the need to search for new methods of surgical treatment of this disease. The main purpose of the operations should be not so much to suturing the hernial orifice, but to restore the full valve function of the esophageal-gastric junction. In addition, the effectiveness of any surgical intervention undertaken for a diaphragmatic hernia largely depends on the experience and skill of the operating surgeon.

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A hiatal hernia is a pathology that manifests itself as a result of an abnormal displacement of internal organs that are physiologically located under the diaphragm (intestinal loops, cardia of the stomach, abdominal segment of the esophagus and other elements). This disease occurs quite often in medicine. The risk of progression of this pathology increases significantly with the patient's age. But it is worth noting that on given time medical statistics are such that hernia of this type is more often diagnosed in middle-aged women.

In more than half of the cases, a hiatal hernia does not manifest itself in any way, and in some cases remains completely unidentified. The statistics are such that an accurate diagnosis of “hiatal hernia” is made only by a third of patients out of the total number of cases. Usually, the pathology is diagnosed by chance, during annual preventive examinations or during treatment in the hospital, but for a completely different reason.

Quite often it happens that patients with such an illness are treated for completely different diseases. For example, from or. This is due to the fact that all these diseases have very similar symptoms. In fact, if you conduct a full diagnosis and prescribe the correct treatment, you can completely get rid of the pathology. Treatment is mainly carried out with several simple operations and medications.

Etiology

The appearance of a hiatal hernia can be associated with either a genetic predisposition or be acquired. Often in children, such a hernia occurs due to a common congenital anomaly - shortening of the esophagus. In this case, there is only one treatment - immediate surgery.

Acquired causes include weakness of the opening of the diaphragm in the esophagus. With age, this lumen becomes less elastic or even atrophies. People with, or are much more susceptible to the progression of this pathology.

It is possible that this pathology will progress simultaneously with other similar lesions. Most often, the pathological process is accompanied by or. Factors that may increase the risk of acquiring a hernia:

• , especially chronic;
• persistent vomiting or passing gas;
• advanced stages;
• difficult working conditions;
• various abdominal injuries;
• pregnancy;
• chronic form or.

These factors contribute to the weakening of the walls of the diaphragm, which, in turn, leads to the collapse of parts of the esophagus and stomach into the chest cavity.

Varieties

Depending on the anatomical structure and cause of formation, there are the following types of hernia:

• sliding;
• peri-esophageal (permanent);
• a type of hernia that combines the two previous types.

A sliding hiatal hernia occurs quite often against the background of all types of hiatal hernia. It also has other names - axial, vagus and axial. With this type, the lower part of the esophagus and the abdominal part freely penetrate into the chest cavity and return to their anatomical position without problems. This happens when a person changes body position (usually from sitting to standing). But not all hernias can be repaired on their own. Often due to their big size And high degree suction of the chest cavity, the hernia remains there, since it cannot go back.

A fixed (permanent) hernia is characterized by the fact that the lower part of the esophagus and stomach fall out of the opening of the diaphragm. Such a hernia is accompanied by nausea, which occurs due to disruption of the passage of food.

At mixed type manifestations of the two above types are combined.

Depending on the extent of displacement of organs into the chest cavity, there are three degrees of hiatal hernia:

• the first - when only the lower part of the esophagus penetrates, and the stomach remains in place, but presses on the diaphragm;
• the second - when the lower part of the esophagus appears in the chest cavity, and the stomach rises and becomes on the same level with the diaphragm;
• the third - penetrates into the chest cavity not only part of the esophagus, but also the bottom of the stomach. Less commonly, loops of the small intestine.

Hernias are divided depending on the organs that form the sac. The sliding is divided into:

• esophageal;
• cardiofundic;
• gastric

Fixed only happens:

• fundic (only the bottom of the stomach);
• antral. When the end part of an organ enters the chest cavity.

Symptoms

More than half of hiatal hernia cases occur without symptoms. It is worth noting that the severity of symptoms directly depends on the size of the hernia. Therefore, the larger it is, the stronger the following symptoms will make themselves felt:

• heartburn of varying degrees of intensity;
• pain in the stomach, which can spread to the back;
• heart pain that spreads down the left side of the body;
• difficulty passing food through the esophagus;
• belching and hiccups;
• hoarseness of voice.

Complications

A hiatal hernia does not always lead to complications. They are strictly individual in nature, depending on what diseases a person has suffered in his life, and on the general level of immunity.

Possible complications may be:

• heart problems, up to;
• stomach ulcer;
• constant burping or regurgitation;
• aspiration pneumonia.

Diagnostics

It is very difficult to carry out diagnostics without tests or devices, because the symptoms are very diverse and are similar to some diseases of the digestive system and gastrointestinal tract.

The main methods for diagnosing a hiatal hernia are x-rays of the esophagus with contrast and measuring acidity in the gastrointestinal tract. You may additionally need to undergo a procedure such as endoscopy.

Treatment

First of all, treatment of such a hernia is aimed at eliminating symptoms with the help of medications that can only be prescribed by a doctor. Self-medication is not acceptable. In addition to medications, the treatment plan includes:

• a diet that the patient must strictly adhere to. It consists of eliminating fried and salty foods from the diet. The last meal should be taken three hours before bedtime;
• reducing the amount of physical activity on the body during treatment.

In cases where drug treatment does not have an effect or the hernia is severely advanced, more serious treatment methods should be undertaken. In this case, doctors resort to surgical intervention. To solve the problem of esophageal hernia in medicine, there are several types of procedures: surgical interventions. Possible options for surgical treatment of a hernia:

• surgical intervention, the essence of which is to sew together the opening through which organs enter the chest cavity, as well as to strengthen the walls of the esophagus;
• gastropexy. The stomach is surgically fixed in a certain position;
• surgical intervention that will restore the correct relationship between the fundus of the stomach and the esophagus;
• in some cases, resection surgery on the esophagus may be necessary.

Once fully recovered, patients who have suffered a hiatal hernia must register with a gastroenterologist.

Prevention

The main preventive remedy for hiatal hernia is proper diet. But you should also follow these recommendations:

• eating in small portions, but with greater frequency throughout the day;
• exclusion from the diet of foods that cause heartburn attacks;
• completely stop drinking alcohol and smoking;
• prevent weight gain;
• during sleep, the head should be fifteen centimeters above the level of the legs.

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Diseases with similar symptoms:

A hiatal hernia, which is also commonly defined as a hiatal hernia (or hiatal hernia), is a disease with a characteristic displacement of an organ located in the abdominal cavity to the chest cavity through the esophageal opening located in the diaphragm. An esophageal hernia, the symptoms of which have pronounced clinical manifestations, is also associated with the specifics of its own formation, which determines its congenital or acquired nature; a hernia can appear as a result of a number of reasons.

A hiatal hernia is a protrusion into the chest cavity of the abdominal segment of the esophagus and the adjacent part of the stomach, and sometimes also intestinal loops, through the enlarged esophageal opening in the diaphragm. In the medical literature, the term “hiatal hernia” is sometimes used in relation to this pathology; in everyday life, simplified names are more often used - esophageal hernia or diaphragmatic hernia.

The disease occurs in approximately 5% of the adult population and is characterized by a chronic relapsing course.

Causes and risk factors

The most common reason the occurrence of hiatal hernias - congenital or acquired weakness of the esophageal ligaments. In approximately half of the cases, the disease is diagnosed in patients over 50 years of age due to progressive degenerative changes in the connective tissue. A sedentary lifestyle, exhaustion and asthenic physique increase the likelihood of the disease. The pathological development of connective tissue structures, which contributes to the appearance of hernias, may be indicated by concomitant diseases: flat feet, varicose veins, hemorrhoids, Marfan syndrome, etc.

The provoking factor for the formation of a hiatal hernia is most often a significant increase in intra-abdominal pressure with prolonged hysterical cough, flatulence, ascites, neoplasms and severe obesity, as well as blunt trauma abdominal area, sharp bends, backbreaking physical labor and immediate lifting of a heavy load. In women, the disease is often diagnosed during pregnancy: according to WHO, hiatal hernias are found in 18% of patients with repeat pregnancies.

A persistent increase in intra-abdominal pressure is also observed in certain diseases of the abdominal organs, accompanied by persistent vomiting and impaired peristalsis. Inflammatory processes in the upper gastrointestinal tract, reflux esophagitis and burns of the mucous membranes lead to cicatricial deformities of the esophagus, which contribute to its longitudinal shortening and weakening of the ligamentous apparatus. For this reason, diaphragmatic hernias are often accompanied by chronic gastritis and gastroduodenitis, gastric and duodenal ulcers, cholecystitis, pancreatitis, etc.

The best prevention of hiatal hernias in the absence of clinical signs is giving up bad habits, balanced diet and regular physical exercise.

In rare cases, the development of a hiatal hernia is caused by congenital anomalies development of the upper gastrointestinal tract. Patients with a short esophagus and the so-called thoracic stomach (congenital shortening of the esophagus) are at risk.

Forms

Depending on the location and anatomical features Hiatal hernias are divided into three groups.

1. Axial (axial, sliding) is the most common type of hiatal hernia, characterized by free penetration of the abdominal segment of the esophagus, cardia and fundus of the stomach into the chest cavity with the possibility of independent return to the abdominal cavity when the body position changes. Taking into account the nature of the dislocation of anatomical structures, among axial hiatal hernias, cardiac, cardiofundal, subtotal and total gastric subtypes are distinguished.
2. Paraesophageal - manifested by displacement of part of the stomach into the chest cavity with the normal location of the distal segment of the esophagus and cardia. Paraesophageal hernias are differentiated into fundal and antral: in the first case, the fundus of the stomach is located above the diaphragm, in the second - the antrum.
3. Mixed hiatal hernias are a combination of the two previous types.

Congenital malformations of the gastrointestinal tract, in which there is an intrathoracic location of the stomach due to insufficient length of the esophagus, should be considered as a separate category.

Hiatal hernia occurs in approximately 5% of the adult population and is characterized by a chronic, recurrent course.

Stages

Based on the degree of displacement of the stomach into the chest cavity, three stages of axial diaphragmatic hernia are distinguished.

1. The abdominal segment is located above the diaphragm, the cardia is at the level of the diaphragm, the stomach is directly adjacent to the cardia.
2. The lower part of the esophagus protrudes into the chest cavity, the stomach is located at the level of the esophageal opening.
3. Most of the subphrenic structures extend into the chest cavity.

Symptoms of a hiatal hernia

In approximately half of cases, hiatal hernia is asymptomatic and is diagnosed accidentally. Clinical manifestations appear as the size of the hernial sac increases and the compensatory capabilities of the sphincter mechanism at the border of the stomach and esophagus are exhausted. As a result, gastroesophageal reflux is observed - the reverse movement of the contents of the stomach and duodenum along the esophagus.

With a large hiatal hernia, reflux esophagitis often develops, or gastroesophageal reflux disease - inflammation of the walls of the esophagus caused by constant irritation of the mucous membranes acidic environment. The main symptoms of a hiatal hernia are associated with the clinical picture of reflux esophagitis, which is characterized by:

• frequent heartburn and a feeling of bitterness in the mouth;
• hiccups and belching with a sour and bitter taste;
• hoarseness and sore throat;
• thinning of tooth enamel;
• pain in the epigastrium, in the epigastric region and behind the sternum, radiating to the back and interscapular region;
• causeless vomiting without previous nausea, mainly at night;
• difficulty swallowing, especially pronounced when taking liquid food and in stressful situations;

Progressive reflux esophagitis is accompanied by the development of erosive gastritis and the formation of peptic ulcers of the esophagus, causing hidden bleeding in the stomach and lower parts esophagus, which lead to anemic syndrome. Patients complain of weakness, headaches, fatigue and low blood pressure; Blueness of the mucous membranes and nails is often noticeable.

When the hernial sac is pinched, the pain sharply intensifies and takes on a cramping character. At the same time, signs appear internal bleeding: nausea, vomiting with blood, cyanosis, sharp decrease in blood pressure.

About a third of patients with a hiatal hernia have cardiac complaints - retrosternal pain radiating to the scapula and shoulder, shortness of breath and heart rhythm disturbances (paroxysmal tachycardia or extrasystole). Differential feature Diaphragmatic hernia in this case is caused by increased pain in a lying position, after eating, when sneezing, coughing, bending forward and passing intestinal gases. After a deep breath, burping and changing posture, the painful sensations usually subside.

Diagnostics

When diagnosing hiatal hernias, instrumental visualization methods play a leading role:

• esophagogastroscopy;
• intraesophageal and intragastric pH-metry;
• esophagomanometry;
• X-ray of the esophagus, stomach and chest organs.

Endoscopic examination allows us to identify reliable signs of a hiatal hernia: enlargement of the esophageal opening, upward displacement of the esophagogastric line and changes in the mucous membranes of the esophagus and stomach, characteristic of chronic esophagitis and gastritis. Esophagogastroscopy is often combined with pH measurement; if severe ulcerations and erosions are detected, selection of a biopsy specimen is also indicated in order to exclude oncopathology and precancerous conditions.

In approximately half of the cases, hiatal hernia is diagnosed in patients over 50 years of age due to progressive degenerative changes in the connective tissue.

On x-rays, signs of axial hernias are clearly visible: high location of the esophagus, protrusion of the cardia above the diaphragm, disappearance of the subphrenic part of the esophagus. When a contrast agent is administered, there is a retention of suspension in the hernia area.

To assess the condition of the upper and lower esophageal sphincters and esophageal motility, esophagomanometry is performed - a functional study using a water-perfusion catheter equipped with a registration sensor. Pressure indicators in the contracted state and at rest make it possible to judge the strength, amplitude, speed and duration of contractions of the sphincters and smooth muscles of the esophageal walls.

Impedansometry allows you to get an idea of ​​the acid-forming, motor-motor and evacuation functions of the stomach, based on the indicators of electrostatic resistance between the electrodes of the esophageal probe. Impedance measurement is considered the most reliable way to recognize gastroesophageal reflux with simultaneous assessment of its type - depending on the pH value, acidic, alkaline or weakly acidic reflux is distinguished.

In case of severe anemic syndrome, a stool test for occult blood is additionally performed. To exclude cardiovascular pathology if you have cardiological complaints, you may need to consult a cardiologist and perform gastrocardiomonitoring - combined daily monitoring of stomach acidity and Holter ECG.

Treatment of hiatal hernia

With a small hernia, medical tactics are usually limited to pharmacotherapy of gastroesophageal reflux, aimed at relieving inflammation, normalizing pH, restoring normal motility and mucous membranes of the upper gastrointestinal tract. The therapeutic regimen includes proton pump inhibitors and histamine receptor blockers; in case of increased acidity, antacids are prescribed - aluminum and magnesium hydroxides, carbonate and magnesium oxide.

The patient must maintain a gentle daily routine, refrain from smoking and alcohol, and avoid stress and excessive physical activity. At severe pain behind the sternum, it is recommended to give the head of the bed an elevated position.

During treatment, you should adhere to diet No. 1 according to Pevzner. The eating regimen is also important: the daily diet is divided into 5–6 servings; it is important that the last evening meal takes place at least three hours before going to bed.

With low effectiveness of drug therapy, dysplasia of the mucous membranes of the esophagus and complicated course of hiatal hernia, surgery is the best solution. Depending on the size and location of the hernial sac, the nature of pathological changes in the esophageal wall, the presence of complications and concomitant diseases, various methods of surgical treatment of hiatal hernias are used:

• strengthening the esophageal-diaphragmatic ligament– suturing of the hernia orifice and hernia repair;
• fundoplication– restoration of the acute angle between the abdominal segment of the esophagus and the fundus of the stomach;
• gastropexy– fixation of the stomach in the abdominal cavity;
• esophagectomy– an extreme measure that is resorted to in the event of the formation of cicatricial stenosis of the esophagus.

Possible complications and consequences

Of the complications of a hiatal hernia, the greatest threat is aspiration pneumonia, which develops when large volumes of stomach contents enter the respiratory tract. Aspiration pneumonia accounts for almost a quarter of all reported cases of severe lung infection. Frequent irritation of the respiratory tract with small portions of regurgitated gastric contents leads to chronic tracheobronchitis.

Also of concern are cardiovascular complications caused by irritation of the vagus nerve by a large hernia. Against the background of a diaphragmatic hernia, reflex angina may develop, and with spasm of the coronary vessels, the risk of myocardial infarction increases.

Lack of treatment for a hiatal hernia provokes complications and increases the degree of cancer risk.

The long-term consequences of a hiatal hernia and the progressive course of reflux esophagitis include:

• the appearance of erosions and peptide ulcers;
• esophageal and gastric bleeding;
• cicatricial stenosis of the esophagus;
• strangulated hernia;
• perforation of the esophagus.

The long course of gastroesophageal reflux with a hernia creates the preconditions for dysplastic and metaplastic changes epithelial tissue mucous membranes of the esophagus. An example of metaplasia with a high probability of malignancy is Barrett's esophagus, which is characterized by the replacement of normal squamous epithelium of the esophageal wall with columnar epithelium characteristic of the intestine, as well as the cardial and fundic sections of the stomach. This creates the preconditions for the development of a malignant tumor process. Metaplastic goblet cells are especially susceptible to malignancy when the length of the affected area is more than 3 cm.

Forecast

With conservative treatment, hiatal hernias are prone to recurrence, therefore, at the end of the main course of treatment, patients are subject to follow-up with a gastroenterologist. After surgery, the likelihood of recurrence is minimal.

Adequate selection of therapeutic regimens and regular prevention of exacerbations of reflux esophagitis make it possible to achieve long-term remission and prevent complications. If the size of the hernia is small and there is a good response to drug therapy, there is a chance of achieving a complete recovery. Lack of treatment, on the contrary, provokes complications and increases the degree of cancer risk.

Prevention

The best prevention of hiatal hernias in the absence of clinical signs is giving up bad habits, a balanced diet and regular exercise. The training program must include specialized exercises to strengthen the abdominal wall.

In order to prevent recurrence of hiatal hernia, it is important to promptly identify and treat diseases of the digestive system, ensure the normal functioning of the gastrointestinal tract and limit the consumption of foods that irritate the mucous membranes. The ban includes spicy, fatty, fried and salty foods, rich broths, smoked meats, alcohol, tomatoes, radishes, cabbage, onions, legumes and citrus fruits, as well as wholemeal bread and cereals rich in fiber. Also, do not get carried away with chocolate, delicacy hard and mold cheeses, red meat and cream cakes.

The most favorable products for restoring the mucous membranes of the esophagus and stomach are considered to be fine-grained cereals, white rice, low-fat milk and meat, ripe sweet fruits without skins and seeds, puddings, soft-boiled eggs, steamed omelettes and boiled vegetables. The healing effect increases many times over if you stick to fractional portions of your diet and find time for walking afterward. evening reception food.

For patients who are prone to obesity, it is advisable to bring their weight into line with the physiological norm. If you have a history of hernia diseases, intense power loads are contraindicated, but exercises in exercise therapy groups have a good effect.

Video from YouTube on the topic of the article:

A hiatal hernia is a chronic disease in which the abdominal esophagus, cardia of the stomach, and sometimes even small intestinal loops are displaced into the chest cavity through the esophageal opening in the diaphragm. This disease is quite common; according to statistics, it affects 5% of the adult population. The disease is most often detected in people over 60 years of age; in women this type of hernia is registered more often than in men.

Predisposing factors in the development of the disease are:

• weakness of the ligamentous apparatus that strengthens the esophagus in the diaphragmatic opening;
• increased intra-abdominal pressure;
• impaired motility of the gastrointestinal tract, resulting in upward displacement of the esophagus.

There are several types of hiatal hernias:

1. An axial (sliding) hernia is characterized by the fact that part of the esophagus, cardia and fundus of the stomach can freely penetrate into the chest cavity and return through the enlarged esophageal opening in the diaphragm. This most often occurs during sleep or with a strong cough.
2. A paraesophageal hernia is characterized by the fact that through the esophageal opening in the diaphragm, part of the fundus of the stomach penetrates into the chest cavity and is located next to the esophagus, and its abdominal part and cardia do not emerge from under the diaphragm.
3. In the mixed version, a combination of sliding and paraesophageal hernias is observed.

Symptoms

In some cases, hiatal hernias are asymptomatic and are discovered accidentally during x-ray examination esophagus or stomach for another reason.

In 50% of cases, the disease is asymptomatic, or its manifestations are so insignificant that patients do not pay any attention to them. Hiatal hernias in such situations are diagnosed by chance during an X-ray examination of the esophagus or stomach for another reason.

The main symptom of the disease is a dull pressing pain, localized in most cases in the epigastric region, spreading along the esophagus and into the interscapular region. Pain syndrome most often occurs after a heavy meal, with physical activity, cough, bloating, lying down. After taking a deep breath, belching, or moving to an upright position, the pain may disappear or decrease.

Quite often, the symptoms of a hiatal hernia are very similar to the signs of cardiac diseases, which complicates diagnosis and can lead to the prescription of incorrect and ineffective treatment.

In a third of patients the main clinical manifestation disease is also pain in the heart area. When a hernia is strangulated, intense constant pain behind the sternum, extending into the interscapular region. Similar symptoms are characteristic of myocardial infarction.

Patients suffering from this disease almost always develop, which is also accompanied by certain symptoms:

• belching of acidic stomach contents, bile or air;
• regurgitation of gastric contents, especially in a horizontal position of the body;
• difficulty passing food through the esophagus, accompanied by unpleasant sensations;
• pain behind the sternum when swallowing;
• bitter taste in the mouth;
• hiccups;
• bouts of persistent coughing at night, caused by stomach contents entering the respiratory tract.

Diagnosis and treatment

The disease is diagnosed based on the patient's characteristic complaints and the results of an X-ray examination of the esophagus and stomach with a contrast agent.

The treatment tactics chosen by the doctor depend on the type of hernia.

Paraesophageal hernias require surgical treatment due to the high risk of strangulation. If this complication does develop, emergency surgery is required.

Sliding hernias, in which the patient does not have any symptoms of the disease, do not require drug treatment. However, patients are advised to follow the instructions developed for patients with diseases of the stomach and esophagus. In addition, patients need to monitor their body weight and avoid obesity, as this contributes to an increase in intra-abdominal pressure. To prevent the reflux of stomach contents into the respiratory tract, it is recommended to sleep with the head of the bed raised.

If symptoms of the disease occur, patients are prescribed medication. To normalize gastrointestinal motility, it is recommended to take prokinetics (Trimedat). Antacid medications (Almagel, Phosphalugel, Gaviscon, Maalox) will help get rid of heartburn.

In case of large axial hernia, the occurrence of ulcers of the esophagus, dysplasia of its mucous membrane and the ineffectiveness of conservative therapy, surgical treatment is recommended for patients.

Which doctor should I contact?

Paraesophageal hernias require surgical treatment.

If you experience pain in the abdomen or chest, especially worse at night and when lying down, you should consult a physician. The doctor will prescribe at least two studies: electrocardiography (ECG) and esophagoduodenoscopy (EFGDS), as well as an x-ray of the esophagus with a radiopaque agent. If a hiatal hernia is confirmed, you need to be treated by a gastroenterologist. In severe cases, surgery is required. It is advisable to consult a cardiologist to exclude cardiac pathology.