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Axial hiatal hernia (sliding and fixed). Symptoms and treatment of hiatal hernia

Hernia food opening diaphragm or hiatal hernia is a displacement of part of the stomach or other abdominal organ into the mediastinum when the esophageal opening of the diaphragm is a hernial orifice. It is a consequence of a decrease in the elasticity of the diaphragm and the esophageal-phrenic ligament, with a parallel increase in the natural opening of the diaphragm, as well as some other gastroenterological diseases. For a long time a hernia can manifest itself only as minor discomfort, which should not be ignored, since it is precisely during early stage For the development of a hernia, conservative treatment may be sufficient. Without treatment, the symptoms of the disease become so severe that surgery becomes inevitable.

With a hiatal hernia, pathological movement of the abdominal organs occurs through the natural opening in the diaphragm into the chest. Pathology can involve organs in whole or in parts, while maintaining mobility or losing it completely. The smaller the area of penetration into a cavity that is unnatural for specific organs, the more favorable the prognosis, but then the symptoms are less pronounced.

For some time the disease does not have specific symptoms, but as the disease progresses, patients begin to notice:

burning pain at the level of the xiphoid process and the lower third of the sternum, intensifying after eating and in a horizontal position;
belching, which, like pain, appears after eating or when a change in body position contributes to the occurrence of reflux;
belching of air, regurgitation;
Rarely, nausea, vomiting, shortness of breath, hiccups, burning of the tongue may occur;
dysphagia (difficulty in swallowing food).

A critical condition is considered to be a herniation of the vessels that supply the organs or the organs themselves. The strangulation can be gradual as the hernia increases - in this case, the vessels are pinched, and disruption of blood flow leads to extensive tissue necrosis. In the event of a sudden provoked injury - from laughter, overeating, heavy exertion - the patient experiences severe pain, the pulse quickens, and the arterial pressure, sweating increases, which is already an indication for emergency hospitalization and surgery.

Etiology of development of hiatal hernia

Causes

In the vast majority of cases, hiatal hernia occurs among the adult population and is a consequence of wear and tear of the body, loss of elasticity of the ligaments, impairment acid-base balance and a combination of acquired parallel ailments. Among the predisposing reasons are:

the presence of untreated gastroenterological reflux disease (GERD);
increased abdominal pressure that occurs during pregnancy, frequent constipation and other disorders of intestinal motility;
the presence of neoplasms in the digestive tract;
weakening ligamentous apparatus, supporting the esophagus and stomach;
constitutional weakness of connective tissue, which is confirmed by their frequent combination with hernias of other localizations, flat feet, varicose veins of the saphenous and hemorrhoidal veins;
esophageal dyskinesia, as well as reflex and symptomatic esophagospasm. (Reflex
esophagospasm is a common disease that occurs against the background various lesions esophagus, gallbladder, stomach, duodenum, cervical and thoracic spine);
being at risk if you have varicose veins, hemorrhoids, overweight, common problems with digestion;
intrauterine pathology of the diaphragm;
acquired abnormality of the length of the esophagus (short esophagus I, II degrees).

A short esophagus is a congenital or acquired pathology of the size and tortuosity of the esophagus, in which a part of the stomach is located supradiaphragmatically.

Of course, some mechanical injuries can also lead to penetration of part of the abdominal organs either through the enlarged opening of the diaphragm or through formed mechanical damage additional holes. In this case, only surgical intervention is recognized as therapy.

Types of hiatal hernia

The most common are two types of hiatal hernia, and a combination of these types is possible.

Sliding (axial) hernia– this is a condition when the cardia is located higher hiatus diaphragm as a result, the relationship between the esophagus and stomach changes, which leads to drastic violation its closing function.
Paraesophageal- characterized by the fact that the cardia does not change its position, and the fundus and greater curvature of the stomach emerge through the enlarged opening

Axial hernia is considered the most common of all hiatal hernias.

Paraesophageal hernia can be antral, fundic, intestinal and omental, where the first 2 types are considered the most common.

Comparative characteristics of the most common hiatal hernias:

Axial (sliding). Labile penetration of the entire abdominal organ or part of it into the food opening of the diaphragm. There are: esophageal (displacement of the abdominal part of the esophagus), cardiac (displacement of the esophagus, cardia of the stomach), cardio-fundal (displacement of the esophagus, cardia and fundus of the stomach). An axial hernia is considered a false hernia because there is no hernial sac.
Paraesophageal is a fixed displacement of the entire stomach or part of it through the food opening of the diaphragm next to the esophagus. There are: antral (displacement of the final part of the stomach) and fundal (displacement of the fundus of the stomach). It is considered a true hernia (a hernial sac is present) with a risk of strangulation.

With a long-term course of the pathology without treatment, the hernia can be differentiated as total or subtotal giant, which is no longer subject to conservative treatment.

Diagnostics

If a hernia is suspected, the gastroenterologist is recommended to ask the patient to bend forward as part of a non-instrumental examination - if there is a hiatal hernia, a sharp burning pain in the chest space with belching, gastroesophageal reflux or heartburn will be observed. And to further clarify the diagnosis and differentiate it from a disease with similar symptoms (myocardial infarction, pancreatitis, intestinal obstruction), instrumental diagnostic methods are recommended, such as:

X-ray of the chest organs;
fluoroscopy of the stomach;
X-ray of the abdominal cavity;
fibrogastroduodenoscopy (FGDS).

FGDS allows you to most accurately determine the location of the hernia and the degree of expansion of the food opening, as well as assess the condition of the esophageal mucosa. When using fluoroscopy, the supradiaphragmatic ampulla of the esophagus is well differentiated from the hiatal hernia, which in turn requires only observational tactics.

A hiatal hernia on fluoroscopy appears as an oval or round body with unclear visualization of the lower border, asymmetrically located in relation to the esophagus.

If a hiatal hernia has been confirmed by fluoroscopy or EGD, stool sampling for occult blood may be indicated if internal bleeding is suspected. During a long course of the disease, a biochemical blood test often has deviations, while clinical analysis parameters may remain within normal limits.

To determine treatment tactics, a biopsy of the esophageal mucosa and pH measurements may be indicated.

Conservative treatment

If the hernia is not total or subtotal in nature, and the patient’s condition is not assessed as severe, the main recommendation for the treatment of hiatal hernia will be the use of all conservative methods, since surgical intervention is usually used only in extreme cases due to the high risk of relapse.

At the same time, you should be aware that conservative technique in 90% of cases it does not eliminate the hernia itself, but only helps to normalize the patient’s life and reduce the risk of complications.

Lifestyle correction

Treatment of hiatal hernia is carried out in outpatient setting under regular medical supervision. After an accurate diagnosis, the doctor prescribes diet and drug treatment, and also gives a number of instructions, neglect of which can worsen the situation and cancel all the benefits of taking medications and correcting nutrition:

A patient with hiatal hernia is prohibited from performing heavy physical activity, lifting weights, or straining the abdominal area. Some types physical therapy, stretching exercises, relaxing the body are welcome.
The use of tight clothing, belts, tights with a rigid waist frame is also prohibited. If the patient, after removing things, notices marks on the abdomen from squeezing the skin, such clothes cannot be worn with hiatal hernia, as they provoke an increase in abdominal pressure.
IN acute period When gastroesophageal reflux and belching manifest, it is recommended to sleep in a semi-sitting position.

Video - Hiatal Hernia

Nutrition

Correction is considered an important aspect familiar image life, since the development of a hiatal hernia is most often due to poor nutrition. It is necessary to ensure a complete diet while maintaining acidity control, that is, exclude hot, spicy, fatty foods that contribute to gas formation and constipation.

Meals should be frequent, fractional, without excess. After eating, you should not take a horizontal position. It is necessary to realize the importance of diet, and not rely only on medications, since after the inevitable withdrawal of medications, in the absence of proper attention to food, a deterioration in well-being will be observed.

Medication assistance

Treatment of an advanced disease only with the help of nutritional correction can take too long, so the body needs medicinal support.

Group of drugs	Antispasmodics and painkillers	Anti-inflammatory drugs	Antacids	Histamine blockers	Prokinetics
Indication	Pain relief	Associated inflammatory processes (with esophagitis)	Binding of already produced hydrochloric acid	Reduced production of hydrochloric acid	Gastrointestinal stimulation
Titles	No-shpa (drotaverine), novocaine	Antibiotics, NSAIDs	Almagel, Phosphalugel, Reni, Gastal, Maalox	Omeprazole, Omez, Ranitidine, Gastroozole, Pantoprazole, Roxatidine, Famotidine	Motilium, Motilak, Ganaton, Trimebutin

It is possible to take astringents, antimicrobials, sedatives and antihistamines using vitamin supplement cyanocobalamin, thiamine, folic acid and pyridoxine. In a hospital setting, physiotherapeutic procedures can be used for up to 10 sessions per course.

It is prohibited to stop taking medications without permission, since even at the very beginning of their use there is a significant improvement in well-being, but talking about a cure is only a matter of time. at this stage extremely untimely.

Traditional methods of treatment

It is worth learning from traditional medicine how to treat a hernia only as a additional method improvement of well-being, if the doctor who determined the tactics of treatment with diet and medication approves the auxiliary intervention.

A good addition to your diet would be to use mild, anti-inflammatory chamomile or lightly brewed green tea. When choosing infusions and herbs, you should look for an option that will reduce stomach acidity, heartburn and abdominal discomfort. Often recommended ginger and lemon teas for hernia and other gastroenterological diseases are contraindicated.

If the conservative method of treating a hernia has not brought success, then surgical intervention is indicated. Since it is associated with certain risks and frequent relapses without eliminating the actual cause of the hernia, they try to resort to it as a last resort. Therefore, the eternal recommendation for the treatment of gastroenterological diseases, especially any type of hiatus hernia, is to take care of your body. Uniform physical activity, monitoring weight and nutrition, avoiding chronic diseases and their timely elimination will help keep the organs healthy and the ligaments strong, and then the risk of hernia formation will be reduced to zero.

Today there are many various diseases. All of them can be divided into 2 large groups: infectious and non-infectious. The latter include pathologies such as hiatal hernia. It is known that normally the chest and abdominal cavities communicate with each other, but organs from one cavity do not move to the other. The very concept of a hernia implies the release of contents (an organ or its part) into another body cavity. Cardiac hiatal hernia is a very common pathology. It refers to diseases of the organs digestive system.

An interesting fact is that in most cases, a hernia is observed in adulthood and old age. It is detected very rarely in children. The risk of developing a hiatal hernia is highest after age 40. If we compare the incidence by gender, then hernia is diagnosed several times more often in women. HH is dangerous because it can go unnoticed by the sick person for a long time. In addition, with prolonged course and inadequate therapy, serious complications, up to cancer. Let us consider in more detail the etiology, clinical picture and treatment of this pathology.

Characteristics of hiatal hernia

Cardiac hiatal hernia is a disease in which the abdominal organs (cardial part of the stomach, part of the intestines) shift upward into the chest cavity. Hiatal hernia can be congenital or acquired. All predisposing factors can be divided into 2 large groups: endogenous (internal) and exogenous (external). Among internal factors, the most important is congenital pathology. Hernia in children occurs precisely for this reason. This reveals a developmental defect, which is characterized by shortening the length of the esophagus. In such a situation, surgery is performed at an early age. Among the acquired factors, the weakness of the ligaments that surround the esophageal opening is of great importance.

It is important that a hernia is typical for people of asthenic physique (those who are tall and thin), and is also detected in physically weak and untrained people. A hiatal hernia can form against the background of such pathologies as Marfan syndrome, flat feet, hemorrhoids, and venous diseases. The reason may be coughing for respiratory diseases. At the core this factor lies an increase in pressure inside the abdominal cavity, which contributes to the expansion of the esophageal opening. Paraesophageal hernia can be fundic or antral. In one case or another, the cause of its formation may be organ pathology gastrointestinal tract.

The pathogenesis in this situation is associated with impaired organ motility. The most important diseases are ulcers, gastroduodenitis, cholecystitis, chronic form pancreatitis. Among external factors, non-diaphragmatic hernia plays an important role in the development of hiatal hernia. balanced diet, which is a risk factor for obesity and ligamentous weakness; traumatic injuries to the abdominal cavity, heavy physical labor. You need to know that a hiatal hernia can occur under certain physiological conditions, for example, during pregnancy.

Clinical manifestations

In about half of the cases, the hernia does not manifest itself at all. Patients may not have any complaints. Cardiac hernia is characterized by the following clinical manifestations:

You can learn more about such a symptom as heartburn by watching this video:

A sick person does not always have all of the above symptoms. A hernia can cause pain syndrome. Pain is observed in the epigastric region. It can be throughout the esophagus. Often the pain radiates to the shoulder girdle or back. A hiatal hernia can in some cases cause chest pain. It resembles that of a heart attack or angina. Of great importance is the fact that a hernia is almost always combined with reflux disease.

With gastroesophageal reflux disease, the patient complains of belching. It can be acidic contents, air. Often a person, being in a horizontal position, regurgitates food. All this is associated with regurgitation (throwing) of food into the esophagus. Sometimes a hernia manifests itself as a persistent cough. It occurs more often at night. A hiatal hernia causes an abnormal heart rhythm in some people.

In the event that the contents of the stomach enter the Airways, possible complications such as bronchial asthma or pneumonia. Patients often develop dysphagia. It manifests itself in difficulty swallowing food. It is important that if you fail to apply for timely medical care a hernia can lead to esophageal cancer. It has been established that every year without appropriate treatment, the risk of developing cancer increases.

Diagnosis of the disease

A hiatal hernia requires accurate diagnosis. The most informative are instrumental research methods. They include FGDS, X-ray examination of the abdominal organs and esophagus. Gastroscopy may be used. Diagnostics involves assessing the condition gastric juice. For this purpose, acidity is measured and gastrocardiomonitoring is performed. By specific method confirmation of the diagnosis of hernia is esophageal manometry.

It is a study of esophageal motility (strength of muscle movements, type of contractions). All this gives an idea of the condition of the esophagus. In addition, manometry assesses the condition of the smallest muscles - the sphincters. They play a large role in regulating the lumen of the esophageal opening. To rule out a tumor, a biopsy of the esophagus is performed. Sometimes your doctor will order a stool test. It can be used to detect the presence internal bleeding.

Therapeutic measures

A hiatal hernia can be treated both conservatively and surgically. It must be remembered that the use of medications allows you to get rid of the symptoms, but the disease remains. After a course of medication therapy will pass, symptoms may reappear after some time. Conservative treatment includes the use of antacids, such as Almagel, Maalox. Histamine receptor blockers and proton pump blockers (Omeprazole) are of great importance.

This picture shows tablets for treating stomach

The patient must monitor his weight, maintain rest and diet. Indications for surgical treatment are the presence of complications, lack of effect from conservative treatment, esophageal dysplasia, strangulated hernia, large hiatal hernia. Thus, diaphragmatic hernia is a serious disease that can lead to complications. The best option is prevention of this disease, since conservative therapy should be carried out for life.

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 medical literature In relation to this pathology, the term “hiatal hernia” is sometimes used; 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 simultaneously lifting 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 for hiatal hernias in the absence of clinical signs is to avoid bad habits, balanced nutrition and regular exercise.

IN in rare cases the development of a hiatal hernia is caused by congenital anomalies development upper sections 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.

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 anatomical structures, among axial hiatal hernias, cardiac, cardiofundal, subtotal and total gastric subtypes are distinguished.
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.
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.

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.
The lower part of the esophagus protrudes into the chest cavity, the stomach is located at the level of the esophageal opening.
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 by chance. 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, or gastroesophageal reflux disease, often develops - inflammation of the walls of the esophagus caused by constant irritation of the mucous membranes by an acidic environment. The main symptoms of a hiatal hernia are associated with clinical picture 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 environments;

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.

In case of strangulation of the hernial sac painful sensations sharply intensify and take on a cramp-like character. At the same time, signs of internal bleeding appear: nausea, vomiting with blood, cyanosis, a 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, it serves to increase pain in supine 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 reveals reliable signs hiatal hernia: expansion 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 subdiaphragmatic part of the esophagus. When inserted contrast agent 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 - 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

For a small hernia medical tactics, as a rule, is 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, avoid stress and excessive physical activity. For severe chest pain, it is recommended to raise the head of the bed.

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 pathological changes walls of the esophagus, the presence of complications and concomitant diseases apply various techniques surgical treatment of hiatal hernias:

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 – last resort, which is resorted to in case of 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.

Complications from of cardio-vascular system caused by irritation vagus nerve 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 during a hernia creates the preconditions for dysplastic and metaplastic changes in the epithelial tissue of the mucous membranes of the esophagus. An example of metaplasia with high probability Malignancy is caused by 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 cardiac 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 surgical intervention the likelihood of relapse 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 adhere to fractional portion meals and find time for hiking after evening reception food.

For patients who are prone to obesity, it is advisable to bring their weight into line with 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 chronic illness, in which there is a displacement of the abdominal part of the esophagus, the cardiac part of the stomach, and sometimes even the loops small intestine, 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:

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.
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.
In the mixed version, a combination of sliding and paraesophageal hernias is observed.

Symptoms

In some cases, hiatal hernias are asymptomatic and are discovered by chance during an X-ray examination of the 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 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 generous intake food, during physical activity, coughing, bloating, while 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 appears behind the sternum, radiating to the interscapular area. 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 treatment is required. surgery.

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.

At large sizes axial hernia, the occurrence of ulcers of the esophagus, dysplasia of the 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 therapist. 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.

The diaphragm is a large and wide muscle that separates the chest cavity from the abdominal cavity. It is, as it were, “stretched” between the sternum, ribs and lumbar vertebrae, to which it is attached. The formation of a hiatal hernia occurs due to its weakening, as a result of which parts of the lower organs penetrate into the upper (thoracic) cavity.

In most cases, small hiatal hernias do not cause problems. If the hernia is large, stomach contents back up into the esophagus, causing heartburn, belching, dysphagia and chest pain.

Causes

A hiatal hernia (abbreviated as hiatal hernia) is diagnosed in approximately 5% of adults. More than half of the cases occur in old age - over 55 years, which is due to age-related changes– in particular, by the natural process of weakening the ligamentous apparatus.

Most often, a diaphragmatic hernia develops due to the fact that the tissues whose task is to limit the esophageal opening of the diaphragm become much more elastic than necessary. Many people don’t even know that such a hernia is possible. Meanwhile it's enough serious problem requiring qualified medical care.

Causes:

Abdominal and chest injuries;
Increased intra-abdominal pressure;
Seizures prolonged cough(asthma, chronic bronchitis);
Connective tissue diseases: Marfan syndrome, systemic scleroderma, systemic lupus erythematosus, dermatomyositis;
Asthenic physique;

Paraesophageal hernia can be congenital or acquired. A hiatal hernia in children is usually associated with an embryonic defect - shortening of the esophagus and requires surgical intervention at an early age.

Those at risk include those who have the following diseases:

Phlebeurysm
Obesity.

Impaired motility also predisposes to the development of a hiatal hernia. digestive tract with hypermotor dyskinesias of the esophagus, accompanying peptic ulcer of the duodenum and stomach, chronic gastroduodenitis, chronic pancreatitis, calculous cholecystitis.

Symptoms of a hiatal hernia

HH is a chronic disease that affects the digestive system, which is in 3rd place among other diseases, such as the duodenum and chronic cholecystitis. A hiatal hernia is a condition in which the stomach slides upward toward the esophagus.

Symptoms of hiatal hernia:

a sign of a diaphragmatic hernia is pain, which is usually localized in the epigastrium, spreads along the esophagus or radiates to the interscapular region and back
chest pain can lead the patient to a cardiologist by mistake in diagnosis;
pain can occur after eating or physical stress, with intestinal tract and after a deep breath;
heartburn, burning in the throat, hiccups, attacks of nausea, vomiting, hoarseness;
cyanosis, vomiting with blood indicate a strangulated hernia;
in some cases, blood pressure may increase.
are celebrated at night severe attacks coughing, accompanied by choking, increased salivation.

The causes of pain with a hernia of the diaphragm are compression of the nerves and vessels of the stomach when its cardiac part enters the chest cavity, the effect of the acidic contents of the intestines and stomach on the mucous membrane of the esophagus and stretching of its walls.

Pain from a hiatal hernia can be differentiated based on the following symptoms:

pain appears mainly after eating, physical activity, in a horizontal position, with increased gas formation;
they soften or disappear after a deep breath, belching, drinking water, changing posture;
the pain intensifies as a result of bending forward.
Sometimes the pain can be tingling in nature, resembling pancreatitis.

Typical symptoms of a hiatal hernia also include:

hiccups;
heartburn;
pain in the tongue, burning sensation;
the appearance of hoarseness.

Contact an ambulance immediately if:

you feel nauseous
you were vomiting
you cannot have a bowel movement or pass gas.

Types of hiatal hernia

There are the following main types of hernias: sliding food hernia (axinal) and fixed (paraesophageal) hernia.

Sliding (axial) hernia

An axial hiatal hernia is a protrusion of organs located below the diaphragm through a natural opening. In the vast majority of cases (approximately 90%) hiatal hernias are axial, or sliding.

With a sliding (axial, axial) hernia, there is free penetration of the abdominal part of the esophagus, cardia and fundus of the stomach through the esophageal opening of the diaphragm into the chest cavity and independent return (when changing body position) back into the abdominal cavity.

An axial hiatal hernia begins to develop with reduced elasticity of muscle connective tissues and weakening of their ligaments. Depending on the area being displaced, they can be cardiac, cardiofundal, subtotal or total gastric.

An axial hernia under the esophagus is characterized by various etiologies. The following etiological factors are distinguished:

Impaired motility of the digestive system
Weakness of the ligaments and other connective tissue elements
High abdominal pressure
The presence of chronic pathology of the stomach, liver, diseases of the respiratory tract, accompanied by intense cough.

Among all diseases of the digestive system this pathology is in third place, representing serious “competition” to such pathological conditions as peptic ulcer stomach and

Fixed hiatal hernia

Fixed (paraesophageal) hiatal hernia is not that common. In this case, part of the stomach is pushed out through the diaphragm and remains there. As a rule, such hernias are not considered a serious disease. However, there is a risk that blood flow to the stomach may be blocked, which can cause serious damage and require immediate medical attention.

Patients with a fixed hernia may experience a symptom such as belching. It appears as a result of air entering the esophagus. Sometimes it gets there with an admixture of bile or gastric juice. In this case, the belching will have a characteristic taste and smell.

Quite often, patients with paraesophageal hernia complain of intense pain in the area of the heart. This is not surprising, because that pain in thoracic region the pain they feel actually mimics the heart.

Degrees of hiatal hernia

It is important to remember that early diagnosis of the disease will help to avoid complications, and treatment will be more effective. In the first stages, you can do without surgery.

In the first, mildest degree, a section of the esophagus rises into the chest cavity, which is normally located in the abdominal cavity (abdominal). The size of the hole does not allow the stomach to rise up, it remains in place;
In the second degree, the abdominal part of the esophagus is located in the chest cavity, and part of the stomach is located directly in the area of the esophageal opening of the diaphragm;
Stage 3 hiatal hernia - a significant part of the stomach, sometimes up to its pylorus, which passes into the duodenum, moves into the chest cavity.

Complications

Complications that may occur with hiatal hernia:

A hiatal hernia may be complicated by the development of gastrointestinal bleeding. The causes of bleeding are peptic ulcers, erosions of the esophagus and stomach.
Another possible but rare complication of a hiatal hernia is strangulation and perforation of the stomach wall.
Anemia is a common complication of hiatal hernia.
is natural and a common complication HHH.

Other complications of a hiatal hernia—retrograde prolapse of the gastric mucosa into the esophagus, intussusception of the esophagus into the hernial part—are rare and are diagnosed by fluoroscopy and endoscopy of the esophagus and stomach.

It is quite obvious that in the listed situations of complications of hiatal hernia, the central goal is to treat the underlying disease.

Diagnostics

To make a diagnosis of a hiatal hernia, you need to describe your complaints to the doctor in detail and undergo a series of examinations. Since this disease is sometimes asymptomatic, a hernia can be detected during a random examination for other complaints.

The diagnosis of hiatal hernia is made on the basis of specific complaints and data instrumental methods research.

These include X-ray examination with contrast, endoscopic examination and manometry, which allows you to measure pressure in different parts of the esophagus.
Additionally prescribed general analysis blood to exclude a potential complication of a hernia - gastrointestinal bleeding.
When, in addition to a diaphragmatic hernia, the patient has cholelithiasis, he needs to go ultrasound examination abdominal cavity.
Since a diaphragmatic hernia is often accompanied by symptoms similar to those of heart disease, an additional electrocardiogram will have to be done.

In any case, studies are prescribed individually, taking into account the characteristics of the patient’s body and the collected medical history.

Treatment of hiatal hernia: drugs and surgery

Treatment of diaphragmatic hernia begins with conservative measures. Since in the clinic of hiatal hernia the symptoms of gastroesophageal reflux come to the fore, conservative treatment is aimed mainly at eliminating them.

Based on the pathogenetic mechanisms and clinical symptoms esophageal opening of the diaphragm, the following main objectives of its conservative treatment can be formulated:

reduction of the aggressive properties of gastric juice and, above all, the content of hydrochloric acid:
prevention and limitation of gastroesophageal reflux;
local medicinal effect on the inflamed mucous membrane of the esophagus, hernial part of the stomach,
reduction or elimination of esophageal and gastric:
prevention and limitation of trauma in the hernial orifice of the abdominal segment of the esophagus and the prolapsing part of the stomach.

Drugs for hiatus hernia

Your doctor may prescribe the following medications for you:

antacids to neutralize stomach acid
H2-histamine receptor blockers, which reduce acid production
proton pump inhibitors (PPIs) - antisecretory medications for the treatment of acid-dependent stomach diseases.
Medicines – proton pump inhibitors and histamine blockers (omez, omeprazole, gastrazole, ranitidine, pantoprazole).
Prokinetics to improve the condition of the mucous membrane of the stomach and esophagus, optimize their motility, relieve nausea, pain (Motilak, Motilium, metoclopramide, Ganaton, itomed, trimebutine).
B vitamins to accelerate the regeneration of stomach tissue.

As a rule, the treatment of diaphragmatic hernia is 99% identical to the treatment tactics for reflux esophagitis. In fact, all actions are aimed solely at eliminating symptoms. The patient can take medications prescribed by the doctor, follow a special diet, and adhere to all the doctor’s instructions.

Surgery for hiatal hernia

Currently, surgery is the only radical and most effective way treatment of hiatal hernia. It is also indicated in the absence of results from drug therapy.

Diaphragm surgery for hiatal hernias is usually planned and performed after careful examination and preparation. Not performed very often emergency operations for complicated hernias (strangulation, perforation or bleeding from a compressed organ).

Operations for hiatal hernia are carried out in different ways. Nissen fundoplication is gaining popularity. During this operation, a cuff is made from part of the stomach wall, which is fixed around the hole where the diaphragm expanded.

Doctors operate in two ways, such as:

removal through an open abdominal incision;
laparoscopy with several small incisions and the use of an endoscope with a camera and optics.

Contraindications for surgery:

Acute infectious diseases.
Exacerbations of chronic diseases.
Heart diseases in the stage of decompensation.
Severe lung diseases with respiratory failure.
Uncompensated diabetes mellitus.
Blood diseases with clotting disorders.
Kidney and liver failure.
Pregnancy.
Oncological diseases.
Recent abdominal surgery.

In the postoperative period, antibiotics, painkillers are prescribed, and if gastrointestinal motility is impaired, prokinetics (cerucal, motilium) are prescribed. The sutures are removed on the 7th day, after which the patient is discharged from the hospital under the supervision of a gastroenterologist.

In the first months, it is necessary to significantly reduce physical activity associated with active movements body.

The most common complications after surgery to remove a hiatal hernia are:

relapse of the disease;
cuff slippage;
feeling of discomfort in the chest area;
pain;
difficulty swallowing;
inflammatory processes;
divergence of seams.

The diet after surgery should be liquid and will need to be followed for approximately 3 to 5 days. Clear liquids consist of broth, water or juice. If after 3-5 days the liquid is well tolerated, the diet will switch to a soft diet.

A soft diet consists of foods that are easy to chew and swallow such as foods softened by cooking or pureing, canned or cooked soft fruits and vegetables, or tender meats, fish and poultry. If the soft diet is tolerated for three weeks, then you can switch to a regular diet.

Diet and nutrition

You need to eat food in small portions. There should be 4-5 meals a day. After eating, it is not advisable to rest in a lying position. It's better to sit or even walk. The movement will stimulate the speedy passage of food from the stomach to other parts of the digestive system.

The diet for hiatus hernia and the menu suggest introducing into the diet:

yesterday's bakery products made from wheat flour;
slimy cereal soups;
sour-milk cuisine;
porridge, pasta;
meat, fish, boiled, baked, steamed;
oils of vegetable and animal origin.

It is prohibited to use seasonings and sugar in dishes for patients with a diaphragmatic hernia, as this provokes increased acidity gastric juice and creates risks for injury to the esophagus.

It is necessary to adhere to a dietary diet, namely:

eat food 5-6 times a day in small portions;
after eating, do not lie down on the bed for 1 hour;
dinner should be 2-3 hours before bedtime;
you can eat grated fruits and vegetables, boiled meat and fish, cereals, jelly, vegetable soups;
before meals, drink 1 tablespoon of sunflower or olive oil;
It is forbidden to eat fried, fatty, salty foods;
Smoking is prohibited.

How to treat a hiatal hernia with folk remedies

For diaphragmatic hernia, herbal treatment against the background of traditional therapy can improve the patient’s condition as a whole and eliminate symptoms. The recipes described below accelerate the secretion of gastric juice, make food move faster through the esophagus, and also eliminate the causes of constipation.

A simple remedy is goat's milk, which should be drunk warm twice a day after meals. A single quantity is 0.5 cups.

Treatment is carried out using a decoction of aspen bark - take a large spoon of the raw material and brew 200 ml of boiling water, infuse and filter. Drink 2 large spoons up to 5 times a day before meals.
You can also use branches of young aspen and cherry. They need to be poured with a liter of boiling water and simmered over low heat for half an hour. Then let it cool and take half a glass.
No less effective, according to traditional healers, is the most common Mint tea. To prepare it, simply add a few dried leaves of the plant to boiling water; you can add sugar to taste (although it is better to abstain if possible). Drink in small sips throughout the day and soon you will forget that you were tormented by pain and heartburn.
You can mix flax seed, anise fruit, marshmallow and gentian roots, and fenugreek in equal parts. The components are crushed, mixed, and a small spoon of powder is taken three times a day. It can be mixed with honey.
Chamomile decoction - good remedy for any manifestations of diaphragmatic hernia. It not only soothes the stomach, but also helps improve digestion. Excellent product, which can safely be called a panacea for all ills.
Calendula tea is also effective. It can be brewed with chamomile. This tea should be drunk no more than four times a day, always no earlier than an hour after meals.

People with this disease are advised to follow the following recommendations:

Patients must follow a special diet that excludes foods that cause intestinal irritation;
Take food in fractional portions every few hours;
Avoid bending the body forward, sudden changes in body position - this can cause pain in the sternum and heartburn;
Patients should not lift weights exceeding 5 kg
You should not tighten your belt too tightly or wear clothes that are tight to your stomach - this creates additional pressure in the abdominal cavity;
Avoid heavy physical activity, but at the same time regularly perform physical therapy exercises that strengthen the muscle corset and restore the tone of the diaphragm;
Recommended last time eat no later than 2.5-3 hours before going to bed;
Normalize stool – constipation and diarrhea increase intra-abdominal pressure and contribute to the formation of hiatal hernia.
Before and after meals, it is recommended to drink a teaspoon of unrefined vegetable oil;

Prevention

In addition to the basic measures to prevent gastroenterological diseases ( healthy image life, eliminating stress, proper nutrition) it is necessary to strengthen the muscular wall of the peritoneum - play sports, therapeutic exercises, pump up the press. Patients with a diagnosed hiatal hernia should be dispensary observation from a gastroenterologist.