Axial esophageal hernia

According to the definitions accepted in gastroenterology, axial means located along the axis, and an axial hernia of the esophagus means that the short distal part of the esophagus with some part of the stomach located in the abdominal cavity moves upward, slips through the esophageal opening of the diaphragm and ends up in the chest - with eventration, that is, protrusion into the posterior part of the mediastinum.

The full medical definition of this pathology is axial hernia of the esophageal opening of the diaphragm. All diaphragmatic hernias according to ICD-10 have the code K44.

Epidemiology

The exact statistics for axial hiatal hernia are unknown, as most studies only consider patients who have symptoms. Although out of ten diagnosed hiatal hernias, nine are axial hiatal hernias.

Almost 60% of patients are aged 50-55 years and older: more than half of them have reflux esophagitis or GERD, and 80% are obese.

In 9% of diagnosed cases, the hernia occurs due to dysfunction of the lower esophageal sphincter, of which in 95% of patients the abdominal esophagus protrudes above the diaphragm along with the upper part of the stomach.

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Causes axial esophageal hernia

This pathology also has other names: sliding axial hernia of the esophageal opening of the diaphragm or simply sliding esophageal, axial hiatal hernia (hiatus oesophageus - esophageal opening), and also axial cardiac hernia of the esophageal opening of the diaphragm, since when protruding, the anatomical position of the cardia changes.

This is an opening in the upper tubular part of the stomach, which has a thin muscular ring called the gastroesophageal, lower esophageal or cardiac sphincter (ostium cardiacum), which ensures one-way movement of swallowed food (into the stomach) and prevents its "reverse flow". And the dysfunction of this sphincter - cardia insufficiency - is recognized as decisive in the etiology of sliding axial hernia of the esophagus.

Listing the possible causes of axial sliding hernia of the esophagus, experts note the following as the main ones: the expansion of the esophageal opening of the diaphragm that occurs with age (instead of 1-1.5 cm to 3-4 cm), shortening of the esophagus itself and an increase in pressure inside the abdominal cavity.

In addition to the fact that in some cases there is a congenital anomaly - idiopathic reduction in the length of the esophagus, its shortening can be caused by systemic autoimmune diseases of the connective tissue, in particular, scleroderma of the esophagus, as well as the chronic form of gastroesophageal reflux disease (GERD). In the latter case, according to experts, the esophagus tube becomes slightly shorter due to a reflex contraction of the longitudinal smooth muscle fibers of its lining under the constant influence of gastric acid.

The cause may also be associated with a decrease in overall muscle tone, affecting the membranes of the visceral organs, the gastrointestinal sphincters, and the diaphragm.

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Risk factors

The following risk factors for the development of axial esophageal hernia should also be taken into account:

• abdominal obesity, accumulation of fluid in the abdominal cavity, severe chronic cough of various etiologies, frequent vomiting, esophagitis, excessive straining during constipation and lifting weights, pregnancy and difficult childbirth (provoking an increase in pressure in the abdominal cavity);
• old age;
• genetic predisposition;
• diseases that lead to a decrease in the length of the esophagus;
• consumption of certain foods (which include fats and hot spices, chocolate and coffee, all alcoholic beverages);
• long-term use of a number of drugs (for example, anticholinergics containing theophylline or progesterone).

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Pathogenesis

Despite all the etiological nuances, in most cases the pathogenesis of the formation of a diaphragmatic axial hernia is explained by the anatomical and physiological characteristics of these structures of the gastrointestinal tract and the disorders occurring in them.

The part of the esophagus that is below the diaphragm (abdominal section) has a length of 20 to 40 mm (the average length is 25 mm). But if – due to anatomical features – it is shorter, then after eating and increasing the pressure in the stomach, the probability of “pushing out” the abdominal section of the esophagus through the hiatus into the area above the diaphragm increases many times. In the chest, the pressure is lower than in the stomach and the entire abdominal cavity, which creates conditions for the return movement of gastric contents into the esophagus (reflux).

Sliding axial hernia of the esophageal orifice of the diaphragm also occurs due to widening of the muscular tunnel of the hiatus itself and/or due to weakening of the phrenoesophageal (diaphragmatic-esophageal) ligament. The upper part of this ligament fixes the esophagus to the upper surface of the diaphragm, and the lower part holds the cardiac part of the stomach to the lower surface of the diaphragm at the cardiac notch of the stomach - ensuring independent movement of the diaphragm and esophagus during breathing and swallowing.

All fascia and ligaments are made up of connective tissue (fibroblasts, collagen and elastin fibers), but as we age, the volume of collagen and elastin fibers decreases, so that the resistance and elasticity of the phrenic-esophageal ligament decreases. As the hernia that has slipped through the esophageal opening above the diaphragm gradually increases, the ligament stretches, displacing the area where the esophagus passes into the stomach (gastroesophageal junction) there as well.

Undifferentiated connective tissue dysplasia is related to the expansion of the esophageal opening of the diaphragm. Today, the clinical manifestations of this pathology include external and internal hernias, reflux (gastroesophageal and duodenogastric), ptosis (prolapse) of internal organs, biliary dyskinesia, etc.

In addition, the pathogenesis of this type of hernia is associated with a violation of the position of the so-called diaphragmatic-esophageal membrane, which is a fold of gastric mucous epithelium covering the site of the gastroesophageal junction. When this fold-membrane is localized too close to the border between the esophagus and the stomach, the cardiac sphincter remains open, which is diagnosed as the above-mentioned cardiac insufficiency.

Each organ in our body has its place. And the violation of the location of organs often becomes the cause of deterioration of their functionality, which cannot but affect the well-being of a person. This also happens with a hernia of the esophageal opening of the diaphragm.

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Axial or hiatal?

Esophageal hernia is a pathology characterized by the migration of gastrointestinal organs through the esophageal opening of the diaphragm into the sternum. The displacement of organs can occur in two ways:

• along the axis of the esophagus, i.e. both the lower end of the esophageal tube and the upper (cardiac part of the stomach), to which it is adjacent, are simultaneously displaced, and then they talk about an axial hernia (doctors call it hiatal),
• penetration into the opening of the body of the stomach and the pylorus (sometimes together with a part of the intestine called the duodenum), while the lower end of the esophagus and the initial part of the stomach remain in place, which corresponds to a paraesophageal hernia.

In some cases, an atypical situation can be observed, when the esophagus and stomach are displaced axially, but intestinal loops also penetrate the opening. This is a mixed type of pathology, which is quite rare.

The opening of the diaphragm, which allows the esophagus from the thoracic region to descend into the abdominal region, which other organs of the upper part of the body cannot, has limited dimensions. Its diameter is slightly more than 2.5 cm. The size of the opening is sufficient for the esophagus to pass through it freely, and for food previously crushed in the oral cavity to move freely in the lumen of the organ. If the diaphragmatic opening increases for some reason, not only the esophageal tube, but also the stomach or a separate part of it can slip through it when the intra-abdominal pressure increases.

Axial or hiatal hernia of the esophagus is the result of weakening or congenital weakness of the ligament that holds the esophagus in a normal position and is located in close proximity to the esophageal opening (Morozov-Savvin ligament), and a decrease in the tone of the diaphragm muscles in the gap area. These are interrelated situations, more typical of age-related changes in the human body, when metabolism slows down, and muscle and connective tissues lose their strength and ability to withstand loads.

Weakening of the diaphragm muscles and ligamentous apparatus is also facilitated by bad habits, including the habit of constantly overeating, excess weight, injuries to the muscle plate separating the chest and abdominal cavity, and physical inactivity, which leads to atrophy of the ligamentous-muscular apparatus. Weakening of the ligament leads to an increase in the diameter of the opening, which allows the esophagus and stomach to shift upward relative to it.

But the above-described moments are only predisposing factors for the development of the disease, which reminds of itself with an increase in intra-abdominal pressure, which, as it were, pushes the abdominal organs beyond the diaphragmatic opening. Situations are especially dangerous when increased pressure in the peritoneum is observed on a permanent basis or the situation is repeated regularly.

This is possible with diseases of the stomach and intestines, accompanied by increased gas formation and chronic constipation, lifting and carrying heavy objects, high physical exertion, prolonged straining cough, typical, for example, for bronchial obstruction. Pregnant women also face increased intra-abdominal pressure due to the growth of the uterus, and a hernia of the esophagus developing in the 2nd-3rd trimester does not even surprise doctors. An identical situation is also observed during straining during childbirth, while the pressure in the peritoneum can increase several times.

The displacement of the esophagus and stomach relative to the opening of the diaphragm can also be caused by anomalies in their structure or pathological processes occurring inside them. For example, a person may have a shortened esophagus from birth, but a decrease in its size can also be caused by an inflammatory process in the tissues of the organ or chronic spasm of the walls of the esophagus.

Inflammation can be caused by reflux disease, when, due to weakness or incomplete closure of the lower esophageal sphincter, food from the stomach mixed with caustic digestive enzymes that irritate the walls of the esophageal tube, which do not have sufficient protection, is regularly thrown into the esophagus. And sometimes the inflammatory process spreads to the esophagus from nearby organs of the digestive system: stomach, intestines, pancreas, liver, because they are all interconnected. Therefore, the presence of any gastrointestinal diseases associated with an inflammatory process or a violation of their motility can be considered a risk factor for the development of axial hernia of the esophagus.

Long-term inflammation in the esophagus is fraught with the replacement of the affected areas with inelastic fibrous tissue, which seems to tighten the organ and thereby reduces its length, as a result of which the esophageal-gastric junction gradually shifts upward, taking with it the cardiac part of the stomach.

As we can see, all these situations are quite common, so it is not surprising that esophageal hernia is gradually approaching gastritis, gastric ulcer and cholecystitis, the recognized leaders among gastrointestinal diseases, in its popularity. At the same time, among the 2 types of esophageal hernia, axial occupies a leading place. Only about 10% of patients diagnosed with "esophageal hernia" have a paraesophageal or mixed form. The remaining 90% are hiatal hernia.

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Symptoms axial esophageal hernia

With a small axial hernia of the esophagus, there may be no symptoms. And the first signs of a sliding axial hernia at the initial stage of the pathology development may manifest as a feeling of a full stomach and heaviness in the hypochondrium of the abdomen, as well as frequent heartburn.

Also noted are acid regurgitation, cough, asthma-like attacks of shortness of breath, hoarseness, and difficulty swallowing (aphagia, less commonly dysphagia).

Heartburn often causes chest pain (slightly above the diaphragm), which is characterized by irradiation to the left shoulder blade and shoulder, which is why patients perceive them as heart pain. But, unlike the latter, pain with an axial hernia becomes more intense after eating and in a horizontal position of the body, and this is evidence that inflammation of the esophageal mucosa is developing - reflux esophagitis or GERD (if the patient did not have it before the hernia formed).

The degrees of axial sliding hernia are distinguished by which anatomical structures move into the thoracic cavity from the abdominal cavity. If it is only the distal (abdominal) section of the esophagus (in this case, the stomach is pulled close to the diaphragm), then axial hernia of the esophagus of the 1st degree is diagnosed. When the lower esophageal sphincter slips through the hiatus and the gastroesophageal junction is localized in it, axial hernia of the esophagus of the 2nd degree is determined, and when the fundus or cardiac sections of the stomach also move and protrude into the mediastinum, axial hernia of the esophagus of the 3rd degree is determined.

It is clear that the higher the degree of hernia, the more complaints patients have – from discomfort in the upper abdominal cavity, heartburn and shortness of breath to severe epigastric pain and increased heart rate – due to irritation of the vagus nerve (nervus vagus), which passes through the esophageal opening of the diaphragm.

Stages

Normally, the esophagogastric junction (the junction of the lower end of the esophagus and the cardia of the stomach) is located 2-3 cm below the opening of the diaphragm, and the body of the stomach is located to the left of the imaginary axis and rests on the left dome of the diaphragm. In the case of an axial hernia of the esophagus, both the lower edge of the esophagus and successively different sections of the stomach, starting from the cardiac section, can shift into the widened opening.

The larger the portion of the stomach that is displaced into the chest cavity, the larger the size of the resulting hernia, which is represented by it. And as the size of the hernia increases, the severity of the symptoms of the disease also increases.

Axial hernia of the esophagus is a progressive disease characterized by gradual weakening of the esophageal-diaphragmatic ligament, its thinning and stretching with a progressive increase in the diameter of the esophageal gap in the diaphragm. And the larger the opening becomes, the more of the stomach can slip into it. In the area of the opening, the organ is somewhat compressed, forming a kind of sac of a larger or smaller size above the diaphragm. It is this sac in the thoracic region that is called a hernia.

Progressive pathology usually has several degrees or stages of development. An axial hernia has three. Let's try to figure out how they differ, what symptoms they are characterized by and what danger they pose.

Axial hernia of the esophagus of the 1st degree is, in fact, the initial stage of the pathology, when only the lower part of the esophagus can shift into the sternum area, and the gastroesophageal anastomosis is located on a par with the opening in the diaphragm. The cardiac part of the stomach, which is normally located a couple of centimeters below the opening, now rests against the diaphragm.

At the first stage of the pathology, there are no stomach disorders associated with its compression. The patient may feel only slight discomfort when taking a deep breath, so he is unlikely to rush to the doctor for an examination. The disease can be detected accidentally during instrumental diagnostics (usually ultrasound or FGDS) in connection with other diseases of the digestive system. And we have already mentioned that a hernia very often occurs against the background of existing inflammatory pathologies of the gastrointestinal tract or with impaired motility of the stomach and intestines, resulting in reflux disease.

Reflux with its characteristic symptoms does not develop at this stage of the pathology (unless it was present initially as a result of inadequate contraction of the stomach walls and weakness of the lower esophageal sphincter).

Axial hernia of the esophagus of the 2nd degree is still considered a mild form of the disease, although due to the expansion of the esophageal opening of the diaphragm, the distal part of the esophagus and the cardiac part of the stomach (cardia and the upper part of the organ) can already penetrate into it. Nevertheless, the compression of the stomach in the diaphragmatic opening is already beginning to affect its performance, so the matter is not limited to just discomfort in the epigastric region.

The patient develops aching pains behind the breastbone, somewhat reminiscent of cardiac pains and radiating to the back between the shoulder blades, heartburn begins to torment (a burning sensation appears along the esophagus), belching (usually air, but with tension in the abdominal muscles or bending over, regurgitation of food is also possible). A sour or bitter taste may appear in the mouth, which disappears with difficulty after drinking water or eating something sweet.

Nausea with axial hernia occurs rarely, unlike reflux, provoked by compression of the stomach and disruption of its motility. The entry of partially digested food with gastric enzymes into the esophagus provokes inflammation of the walls. And if at first the pains arose only when straining, lifting weights and overeating, now they can appear when bending over and in a horizontal position of the body, and later without any particular reason.

Impaired gastric motility at stage 2 of the disease is fraught with digestive disorders, when diarrhea and constipation alternate. Problematic defecation causes regular straining and tension of the abdominal muscles with increased pressure inside the abdominal cavity. All this aggravates the situation and contributes to the growth of the hernia. The situation worsens as inflammation in the esophagus develops, caused by reflux, although serious complications are not yet being discussed.

Axial hernia of the esophagus of the 3rd degree is the most dangerous stage of the disease, in which the risk of various complications is maximum. Now any of the sections of the stomach, and in some cases even its pylorus and duodenum, can be in the opening of the diaphragm.

Since this stage of the disease was preceded by 2 others that made their undesirable contribution to the condition and functioning of the stomach and esophagus, the symptoms of the disease not only do not subside, but even become more pronounced. The 3rd stage of the pathology is characterized by a whole complex of symptoms of esophageal hernia: heartburn caused by reflux (and at this stage, almost all patients complain of it), belching, pain behind the breastbone and in the abdominal cavity, hiccups, dysphagia.

Reflux of gastric contents causes a burning sensation along the esophageal tube, associated with irritation of its walls by digestive enzymes. The longer and more regularly food is refluxed into the esophagus, the greater the likelihood of developing inflammatory-degenerative changes in the organ, causing replacement of the mucous membrane with inelastic fibrous tissue, which under load can burst with the formation of ulcers and hemorrhages. This pathological condition is called reflux esophagitis, which is considered a common complication of esophageal hernia.

The formation of scars on the walls of the esophagus reduces its lumen, causing stenosis of the organ, which is considered a chronic condition, unlike spasm of the muscles of the esophagus, and is a problem for the passage of food through the esophageal tube. The patient is forced to eat food in small sips, reduce its one-time volume, give preference to liquid dishes, which leads to a sharp decrease in weight, deficiency of vitamins and minerals. Along with bleeding, this provokes the development of iron deficiency anemia, vitamin deficiency, exhaustion.

When gastric contents are thrown into the oral cavity, the walls of not only the esophagus, but also the pharynx become inflamed, as a result of which the patient’s voice changes, becomes less clear, hoarse, and muffled.

Hiccups, which in case of hiatal hernia of the esophagus are distinguished by an enviable duration and intensity, are provoked by compression of the phrenic nerve by a growing hernia. Irritation of the nerve endings causes uncontrolled contractions of the diaphragm with expulsion of air and specific sounds. Apart from unpleasant sensations, this symptom does not pose any danger, but in some situations it can cause psychological discomfort.

Displacement in the diaphragmatic opening of the esophagus, stomach and intestines is accompanied by pain, which gradually turns from aching into burning. Axial hernia of the esophagus has another name - sliding, because when changing the position of the body, increasing or decreasing intra-abdominal pressure, it can shift up or down. Its movement is accompanied by an increase in pain, and sometimes, if it happened after a heavy meal, and regurgitation of food. Some patients note the appearance of spastic pain not only in the stomach, but also in the intestines.

Pain can significantly worsen the quality of life of patients. It increases in the horizontal position, which prevents patients from having a normal night's rest, causing frequent awakenings and problems falling asleep. Lack of night rest and chronic pain have a negative impact on the psycho-emotional state of patients, communication skills, and performance.

Increased intragastric pressure in case of esophageal hernia as a result of its compression by the diaphragmatic opening and chest organs stimulates a sharp release of air swallowed during food intake. This process is called belching. In a healthy person, air comes out slowly and gradually, and with increased pressure in the stomach - abruptly, with effort and accompanied by a loud, unpleasant sound.

If the patient has increased acidity of gastric juice, he will complain of the appearance of sour belching, which is an additional factor in irritation of the esophageal walls. In diseases of the pancreas and liver, as well as when intestinal loops enter the abdominal cavity, belching can become bitter, which indicates the presence of bile and pancreatic enzymes in the stomach.

Patients with grade 3 esophageal hernia often experience regurgitation, i.e. regurgitation of food without the preliminary urge to vomit. When changing body position or during physical activity after eating, food can flow back into the esophagus and even the oral cavity. The high severity of this symptom forces a person to carry special bags for spitting out the "backflow". From the outside, this looks depressing and can cause severe psychological discomfort, isolation, decreased self-esteem, and limitation of social activities.

Another problem typical of axial esophageal hernia is esophageal dysphagia or swallowing disorder in the lower esophageal sphincter. This symptom can be caused by long-term reflux disease, irritation and strictures of the esophagus, or spasm of the organ muscles as a result of the same irritation, but of the nerve endings responsible for contractile movements of the esophageal tube.

The more severe the stenosis, the more difficult it is for the patient to eat. At first, problems arise when eating solid food, then difficulties begin with the intake of semi-liquid and liquid food. And it all can end with the inability to drink water or swallow saliva due to severe stenosis, which requires surgical intervention and restoration of communication between the esophagus and the stomach.

With dysphagia, the patient's complaints are limited to a feeling of a lump in the throat and discomfort in the mediastinum. Drinking liquid does not solve the problem. As the lumen narrows, the patient's diet, eating regimen, and portion size have to be changed, which are considered auxiliary measures. If nothing is done, the lumen of the esophagus will decrease due to chronic inflammation, which indirectly leads to exhaustion of the patient and even to his death.

Axial or sliding hernia of the esophagus, despite all its unpleasant symptoms, is considered a less dangerous pathology than its paraesophageal variety. Due to the mobility of the organs inside the diaphragmatic opening, the symptoms may subside and then reappear during physical activity and a change in body position. But you can’t count on the organs returning to their normal position on their own and staying there forever, so when the first signs of gastrointestinal pathology appear, you need to contact a gastroenterologist for a consultation, diagnostics and treatment corresponding to the current stage of the disease.

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Forms

In the absence of a unified classification, there are such forms or types of axial hernia of the esophagus as congenital (arising due to an initially increased size of the hiatus or a short esophagus) and acquired; non-fixed (spontaneously corrected when the body is in an upright position) and fixed (in rare cases).

Based on the part of the stomach protruding above the diaphragm, the following are also determined: axial cardiac hernia of the esophageal opening of the diaphragm, cardiofundal, subtotal and total gastric.

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Complications and consequences

Many gastroenterologists claim that such a complication as strangulation does not occur with a sliding axial hernia of the esophagus, since its hernial orifice is a pathologically widened natural anatomical opening of the diaphragm.

But in rare cases this is possible: with postural defects or curvature of the spine. This is due to an increase in the natural anterior concavity of the thoracic esophagus in the sagittal plane.

More likely consequences and complications are: erosion of the esophagus and ulcerative esophagitis (with pain and burning behind the breastbone and the threat of esophageal perforation); prolapse of part of the gastric mucosa into the esophagus; hidden bleeding (leading to anemia); reflex (vagal) cardialgia.

The most dangerous complication is Barrett's esophagus - with metaplastic processes in the epithelium of the esophageal mucosa and the risk of developing oncology.

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Diagnostics axial esophageal hernia

In addition to anamnesis and palpation of the abdominal area, diagnosis involves a general clinical blood test and, if necessary, determination of the pH of gastric juice.

Instrumental diagnostics are performed by means of: X-ray (with barium) and ultrasonography of the esophagus and stomach, their endoscopic examination and esophageal (esophageal) manometry, CT. In case of cardialgia, an ECG is mandatory.

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Differential diagnosis

Differential diagnostics, taking into account the similarity of symptoms, is aimed at not mistaking for a sliding axial hernia: superficial gastritis, inflammation of the mucous membrane of the duodenum - duodenitis, diverticulum of the esophagus and dilation of its veins, supradiaphragmatic expansion of the ampulla of the esophagus, ischemic heart disease, angina pectoris, etc.

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Treatment axial esophageal hernia

It is not worth dwelling on the fact that any disease requires adequate treatment, and the sooner it is started, the easier it is to overcome the disease. We have been told about this many times, and a hernia of the esophagus is an excellent confirmation of this. The doctor's prescriptions for this disease strictly depend on the stage of development of the pathology. Their volume increases from changing the diet at the initial stage of the disease, to surgical intervention at the last, when the risk of complications threatening the health and life of the patient is high.

To treat axial hernia of the esophagus of the 1st degree, in which there are no symptoms of malaise or they are expressed insignificantly, it is usually enough to correct the patient's lifestyle. The patient is recommended to avoid sharp bends of the body, lifting weights, rest more, practice dosed physical activity, which will help normalize the work of the gastrointestinal tract, prevent constipation, improve metabolism.

Hypodynamia with this pathology will only complicate the course of the disease, so you need to walk, ride a bike, and jog every day. The possibilities of sports training should be discussed with a doctor, but heavy sports are definitely contraindicated with an esophageal hernia.

Particular attention should be paid to the patient's diet. A diet for axial esophageal hernia involves limiting the consumption of heavy and spicy food that irritates the mucous membrane of the gastrointestinal tract, including alcohol and carbonated drinks. The latter, along with hard-to-digest fatty foods, causes flatulence and increased intra-abdominal pressure, which is very undesirable for this disease.

The diet should be complete, rich in vitamins and microelements, but at the same time light, which will help relieve the digestive organs and timely, problem-free bowel movements without straining. Fractional meals with a frequency of up to 6 meals a day are recommended. Portions should be sufficient for satiety, but not leading to overeating. If you are overweight, you will have to fight it through moderate physical activity and reducing the caloric content of portions.

Drug therapy is not performed in the absence of reflux disease symptoms and severe pain. However, if the patient suffers from constipation or has digestive problems caused by concomitant diseases, it will be necessary to regularly take laxatives, enzyme preparations and other necessary medications that will make digestion comfortable.

If reflux occurs, you will need to take heartburn medications, i.e. those that reduce the acidity of gastric juice and, accordingly, its irritating effect on the walls of the esophagus, and have an enveloping and analgesic effect:

• antacids (Phosphalugel, Almagel, Rennie, Maalox, Gastal),
• proton pump blockers (Omez, Omeprazole, Pantoprazole, Nexicum),
• histamine receptor inhibitors used in gastroenterology (Ranitidine, Famotidine, Rinit, Quatemal, Famatel).

To normalize the motility of the stomach and intestines, which helps reduce the frequency of reflux episodes, drugs from the prokinetic category are prescribed: "Domperidone", "meoclopramide", "Cerucal", "Motilium", "Primer", etc. These drugs promote the effective movement of the food bolus along the digestive chain and timely bowel movement, which makes it possible to refuse to take laxatives.

In case of reflux disease, all the above-described requirements for lifestyle are especially relevant. And from the exercise therapy complex, such patients should pay special attention to breathing exercises, which safely and effectively train the muscles of the diaphragm and organs located in the thoracic and abdominal regions.

In the treatment of axial hernia of the esophagus grade 2, when symptoms of reflux disease manifest themselves to one degree or another, the use of medications that improve the functioning of the digestive system, reduce the acidity of gastric juice and reduce its secretion, becomes even more relevant.

The requirements for the diet also become more stringent, from which all products and dishes that stimulate the synthesis of digestive enzymes, increase the production of gastric juice and its acidity must be excluded. In general, the diet for stages 1 and 2 of the pathology is practically no different.

Drug therapy is the same as that used for reflux disease. It involves taking medications that correct the acidity of the stomach and the production of caustic digestive enzymes, prokinetics and enzyme preparations that optimize digestion, and, if necessary, antispasmodics (indicated for esophageal spasm or predisposition to it).

For both the first and second degree of axial esophageal hernia, the use of folk recipes with the appropriate mechanism of action is allowed, but the possibilities and safety of their use must be discussed with a doctor.

The patient's physical activity remains at the same level. Lifting weights becomes extremely undesirable, as does any excessive tension in the abdominal muscles, which provokes an increase in intra-abdominal pressure. Physical therapy exercises should be performed regularly and preferably under the supervision of a specialist (at least at first).

Axial hernia of the esophagus of the 3rd degree is treated by analogy with the second degree before complications develop. But if the treatment does not give good results and the hernia is complicated by a strong shortening of the esophagus, a violation of its patency due to stenosis, reflux esophagitis, the development or progression of gastric ulcer and duodenal ulcer, gastrointestinal bleeding, heart problems, phrenopyloric syndrome, etc., surgical treatment is prescribed, combining laparoscopic surgery with plastic surgery of the tissues of the diaphragmatic opening.

Regardless of the type of surgery performed, the patient is prescribed a diet, medication, lifestyle correction, and exercise therapy. The likelihood of relapse of the disease depends on this, because a severe axial hernia of the esophagus implies a number of serious disorders in the functioning of the digestive system and ligamentous apparatus, for the correction of which surgical intervention alone is not enough.

There is no need to treat asymptomatic (incidentally discovered) axial hiatal hernias.

In most cases of axial esophageal hernia that cause patient complaints, treatment is symptomatic.

Symptoms of the pathology can be alleviated by medications such as antacids - Almagel, Fosfalugel, Gastal, etc.; H2-histamine receptor blockers (Gastrosidine, Famotidine, Ranitidine).

Dosage, contraindications and side effects see - Heartburn Tablets

Drugs such as Pantoprazole, Omeprazole, Rabifin, etc. are considered more effective in reducing acid secretion in the stomach, but they must be used for a long time, which increases the risk of side effects (increased bone fragility and kidney dysfunction).

If the condition does not improve after drug therapy, surgical treatment is performed in the form of operations such as gastrocardiopexy (according to the Hill method) and laparoscopic fundoplication (according to the Nissen method). Details in the publication - Diaphragmatic hernia

However, surgical intervention does not guarantee the occurrence of relapses, the frequency of which increases with large hernias and the presence of obesity in patients.

The attending physician recommends excluding from the diet foods that increase acidity and prescribes a diet for axial hernia. The necessary changes in nutrition are taken into account as much as possible Diet for heartburn, as well as Diet for esophagitis

Prevention

In order to prevent this pathology, you should avoid any factors that can increase intra-abdominal pressure, first of all, normalize your body weight and establish regular bowel movements.

It is also recommended to adjust eating habits (including not eating three hours before bed) and to give up alcohol and smoking.

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Forecast

Is it possible to fully recover from an axial hiatal hernia? Unfortunately, it is a chronic, recurring disease. The overall prognosis for life is positive; symptomatic treatment and surgery provide relief to most patients, although some will continue to have symptoms.

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