Paraesophageal hernia is the displacement of anatomical structures into the chest cavity through the diaphragm. The disease is serious, it requires surgical treatment. It is also quite rare, found in only 0.5-1% of all cases of hernias.
What are the causes of this pathology? What are the prerequisites? And by what symptoms can you learn about its development? These and many other questions are answered in the article.
Briefly about pathology
The lower part of the esophagus (cardia) under normal conditions performs a barrier function. It prevents the entry of organs from the abdominal cavity through the diaphragmatic opening. However, under the influence of negative factors, the protective force weakens. Because of this, the organs penetrate the chest cavity. Of course, this pathological phenomenon is accompanied by a feeling of heaviness and specific symptoms (they will be listed below).
Sometimes wall weakness is called cardia failure. This phenomenon is accompanied by an increase in the level of pressure in the abdominal cavity, and its decrease in the chest.
As a rule, the presence of this pathology is detected during the examination by a gastroenterologist. The older the organ is from a physiological point of view, the higher the risk of paraesophageal hernia. With age, chronic diseases grow stronger, develop, and this contributes to the protrusion of the abdominal organs.
According to statistics, patients whose age does not exceed 35 years experience this disease in 40% of cases. After 60 years, the risk increases to 60%. As a rule, paraesophageal hernia occurs more often in women. This is due to the anatomical features of their body.
Provocative factors
The cause of a hiatal hernia (ICD-10 code: K44) is chronic respiratory disease and high abdominal pressure. However, provocative factors can always occur. These include:
- Ailments that are accompanied by connective tissue disorders - hemorrhoids, flat feet, Marfan syndrome and varicose veins.
- Gastrointestinal diseases associated with impaired motor skills: chronic pancreatitis, dyskinesia, gastroduodenitis, ulcers.
- Hernia of the umbilical region, white line of the abdomen, femoral protrusion.
- Weakness of the ligamentous apparatus of the diaphragm of an acquired nature.
- A sharp increase in pressure, which can cause chronic constipation, profuse vomiting, trauma to the abdominal cavity or increased activity.
- Repeated pregnancy.
- Scarring and deformation of the esophagus.
- Hormonal disorders.
- Operations on the abdominal organs.
It is important to note that the hernia of the esophageal opening of the diaphragm (code according to ICD-10: K44) can begin to develop not only at some particular moment in life - it can also be congenital.
Sliding hernia
Like any other disease, this pathology has several forms of manifestation. Two, to be precise. The difference between a sliding hernia and a paraesophageal (fixed) one is that it protects the protrusion through the natural opening of those organs that are below the diaphragm.
This form of pathology develops as a result of weakening of the ligaments of the muscle connective tissues and because of their reduced elasticity.
From etiological factors distinguish:
- Increased pressure in the abdominal cavity.
- Impaired gastrointestinal motility.
- The presence of pathologies of a chronic nature that relate to the liver, stomach, respiratory tract.
- Weakness of the ligamentous apparatus and other connective tissue elements.
Talking about the causes and symptoms of a hiatal hernia (treatment will be discussed later), it should be noted that among all gastrointestinal ailments, this pathology takes 3rd place, it occurs slightly less often than ulcers and cholecystitis.
Fixed hernia (GPOD)
It is less common in the form mentioned above. In this case, part of the stomach is simply pushed through the diaphragm, where it then remains. This pathology has a risk - the flow of blood to the organ may be blocked. And this is fraught with serious damage.
Most often, the pathology is manifested by belching. It occurs due to air entering the esophagus. Sometimes he is there with an admixture of gastric juice or bile. In this case, belching acquires a characteristic smell and aftertaste.
Often people with a fixed hernia complain of severe pain in the heart. This does not mean that they have problems of this nature. Just the pain they feel really reminds imitates the heart.
Degrees of GPOD
Early diagnosis of a hiatal hernia helps to avoid severe complications and the development of the disease. At an early stage, it is quite possible to do without surgical intervention. And there are three of them:
- First one. The lightest. It is characterized by a rise in the chest cavity of the esophagus. The size of the hole does not allow the stomach to reach the top, because it remains in place.
- The second one. In the chest cavity there is already a whole abdominal esophagus. A part of the stomach is observed in the area of the opening of the diaphragm.
- The third. It is characterized by the fact that most of the stomach (sometimes even right up to the pylorus) rises into the chest cavity.
Signs of the disease
Having studied the causes of paraesophageal hernia, we can proceed to consider the symptoms indicating its presence. The most striking signs include:
- Pain, localized in the epigastrium. It radiates to the back and the area between the shoulder blades, spreading along the esophagus.
- Increased pain after physical exertion and eating. The same is observed with a deep breath and intestinal flatulence.
- Discomfort in chest pain.
- Hiccups, burning in the throat, heartburn, hoarseness and the urge to vomit.
- High blood pressure.
- Vomiting with blood, cyanosis.
- Severe coughing attacks, especially at night. May be accompanied by increased salivation and suffocation.
Differentiation of pain
The discomfort that occurs with paraesophageal hernia can be distinguished by taking such signs as a basis:
- Pain occurs during physical exertion, after eating food, as well as with increased gas formation and during a long stay in a horizontal position.
- Discomfort disappears or softens after burping, taking a deep breath, changing posture, or drinking.
- The pain is aggravated by leaning forward.
- Sometimes discomfort is girdling, which resembles pancreatitis.
Pain can be accompanied by the appearance of heartburn, hiccups, discomfort in the tongue (possibly even burning), hoarseness, nausea, vomiting, and the inability to release gases and empty the intestines.
Complications
What is the danger of paraesophageal hernia? If left untreated, complications will arise. Namely:
- Gastrointestinal bleeding caused by erosion of the stomach of the esophagus, peptic ulcers.
- Reflux esophagitis.
- Perforation of the wall of the stomach and infringement of a hernia.
- Anemia.
Less commonly, the consequences of paraesophageal hernia are esophageal invagination and retrograde mucosal prolapse. These complications are determined by endoscopy and fluoroscopy.
Diagnostics
It is necessary to tell about its implementation before discussing the principles of therapy and treatment. Symptoms of a hernia of the esophageal opening of the diaphragm are specific, and therefore, having noticed any manifestations from the previously listed, one must go to a gastroenterologist.
After the survey and visual inspection, instrumental studies are carried out:
- X-ray with contrast.
- Pressure gauge and endoscopic examination.
- General blood analysis.
- Ultrasound of the abdomen.
- Electrocardiography
Other activities may also be required. It all depends on the history of the patient and the characteristics of his body.
Principles of Therapy
The causes and symptoms of diaphragmatic hernia were examined above. Treatment also needs to be described. They begin it with conservative therapy. It is aimed at eliminating the symptoms of gastroesophageal reflux.
But in general, based on clinical signs and pathogenetic mechanisms, the objectives of therapy can be formulated as follows:
- Reducing the aggressive properties of the juice secreted by the stomach. Reducing the content of hydrochloric acid in it.
- Limiting and preventing gastroesophageal reflux.
- Reduction of gastric and esophageal dyskinesia. Ideally, its complete elimination.
- Local exposure via medication to inflamed mucosa.
- Limitation and prevention of injuries in the prolapse of the stomach, as well as in the hernia gate of the esophageal abdominal segment.
Featured Drugs
Since we are talking about eliminating the symptoms of diaphragmatic hernia and treating this ailment, it is also necessary to list medications that can help cope with it. They are selected by the doctor individually, but, as a rule, the following drugs are prescribed:
- H2-histamine receptor blockers. Acid production is minimized.
- Antacids. They neutralize stomach acid.
- Proton pump inhibitors. They are effective in eliminating acid-dependent diseases of the stomach.
- Combined drugs: Omez, Pantoprazole, Ranitidine, Omeprazole, Gastrozole. They combine the action of blockers and inhibitors.
- Prokinetics. Positive effect on the mucous membrane of the esophagus and stomach, optimize their motility, relieve pain and nausea. The best drugs are Trimebutin, Motilak, Itomed, Motilium, Ganaton and Metoclopramide.
- Vitamins of group B. They must be taken in order to accelerate the regeneration of the tissues of the stomach.
Surgical intervention
Surgery is the most effective way to repair a hernia. And the only true method in cases where conservative therapy is unsuccessful.
The operation is carried out after a detailed examination and thorough preparation. They plan to intervene, but occasionally emergency cases occur due to bleeding, perforation or infringement.
Recently, Nissen fundoplication is more often performed. The principle of operation is to create a cuff from a part of the wall of the stomach that is fixed around the opening with expansion.
They operate in two ways. An abdominal, open incision, or laparoscopy, involving the use of an endoscope, can be performed.
There are contraindications. Among them:
- Exacerbation of ailments of a chronic nature.
- Blood diseases.
- Diabetes mellitus (uncompensated).
- Infectious diseases.
- Respiratory failure, lung problems.
- Heart diseases that are in the stage of decompensation.
- Oncological neoplasms.
- Pregnancy.
- Recently performed abdominal surgery.
Rehabilitation takes some time. The stitches are removed after a week, all this time a person should drink painkillers, antibiotics and prokinetics (if motility is impaired).
Diet
Of course, with a hiatal hernia, the patient will have to reconsider the menu. The diet will need to introduce such products:
- Mucous cereal soups.
- Dried baked goods made from wheat flour.
- Dairy products.
- Macaroni and porridge.
- Low-fat fish and meat, steamed or by baking / boiling.
- Animal and vegetable oils.
- Mashed vegetables and fruits, jelly, vegetable soups, jelly.
It will be necessary to refuse sugar, seasonings, all salty, spicy, fatty, spicy. Take food 5-6 times a day, after eating for 60 minutes do not go to bed. Have dinner at least 2-3 hours before bedtime. Before eating, it is recommended to use 1 tbsp. l olive oil. It is also forbidden to smoke.
And as a prophylaxis, it is recommended to drink a decoction of chamomile or tea with calendula. Drinks are prepared elementary - 2-3 tbsp. l herbs are boiled with boiling water. Before use, they are insisted and filtered.