Hernia of the esophagus: causes, signs, how to treat?

Pathologies associated with the disruption of the gastrointestinal tract are always a big nuisance for a person, because they interfere with one of his basic physiological needs - nutrition. The esophagus is an integral link in the system of food delivery into the stomach, where its digestion begins. It is a fairly narrow tube of muscles, the length of which in an adult is a quarter of a meter. Getting from the mouth to the esophagus, food is saturated with mucus and with the help of their contraction - peristalsis moves to the stomach. It ends with a sphincter - a special locking system that does not allow the contents to go back. Despite the simplicity of the anatomy of the organ, there are many of its pathologies, including a hernia of the esophageal opening of the diaphragm.

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Epidemiology

According to statistics, when examining esophageal hernias, they are found in 5-7% of patients who have come with complaints of stomach problems. Of all types of hernias, these make up 2%. Women are more susceptible to it than men and older people.

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Causes esophageal hernia

The main tendency for hernias to appear is an imbalance between intra-abdominal pressure and the resistance of the abdominal muscles. Why does this happen? The reasons leading to this may be:

• features of a person's constitution that were passed on to him by inheritance;
• age-related changes accompanied by thinning of connective tissues;
• pregnancy, difficult childbirth;
• physical labor that requires great effort;
• weight change: obesity or emaciation;
• chronic pathologies of the digestive system associated with impaired motility of the stomach, gallbladder, duodenum;
• certain diseases of the endocrine glands.

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Risk factors

Based on the reasons leading to the formation of hernias, we can identify the risk factors that provoke their appearance:

• elderly age;
• abdominal trauma;
• chronic constipation;
• difficulty urinating with prostate adenoma;
• severe continuous cough caused by diseases of the bronchopulmonary system, for example, chronic obstructive bronchitis;
• bad habits.

The localization and character of the hernia depends on the interaction of these factors.

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Pathogenesis

What is a hernia of the esophageal opening of the diaphragm, another name for it is hiatal? The diaphragm is the main muscle that separates the space with the abdominal organs from the chest. It has a dome-shaped form, directed upward, with an opening for the esophagus in the center. The pathogenesis of the disease consists in the displacement of one or another organ of the abdominal cavity to the chest through this opening due to weakening of the diaphragm, as well as another defect. This occurs during inhalation, when the opening expands and the so-called hernial orifice is formed. At this time, the organs of the peritoneum gain free access to the chest and move there.

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Symptoms esophageal hernia

The first signs that testify to the hernia of the esophagus are:

• heartburn - is observed in the majority of patients: from mild, almost not affecting the condition, to severe, not giving to work. Most often occurs when the slopes, after eating, can intensify at night;
• pain - how does the hernia of the esophagus hurt? It is peculiar to feel in the lying position and during inclinations, it can be confused with heart attacks. Sometimes she is shrouded in nature, given in the back. The intensity of pain is affected by the existing heart disease;
• belching of the air, sometimes the contents of the stomach, after which there are severe pain behind the sternum or in the epigastric region, disappearing when taking funds that neutralize the action of hydrochloric acid;
• regurgitation, is observed in a third of patients. It appears when you lean, eat or lie down. Vomit, at the same time, are quite plentiful, they contain eaten food or gastric sour juice;
• com in the throat - appears with the use of liquid food, rapid chewing;
• dysphagia or swallowing disorders, occurs from 7% to 40% of cases, often occurs when eating contrasting temperatures;
• Hiccup (about 3% of patients) is usually associated with food intake, and lasts for a long time;
• bloating - there is pressure in its upper part;
• a burning sensation and even pain in the throat, tongue - arises from the burn of the oral cavity and larynx with gastric contents with hydrochloric acid falling into regurgitation;
• temperature - rarely, but there is an increase to 37.1-38 ⁰ C for a long time.

Hernia of the esophagus in the child

The prerequisite for the hernia of the esophagus in the child is thinning the muscular layer of the diaphragm at an early stage in the development of the embryo or fetus. This is due to the peculiarities of the exchange between the mother and the future child. Further, intra-abdominal pressure leads to the protrusion of the digestive organs into this underdeveloped diaphragm. There are also acquired hernias. They arise due to closed injuries of the abdomen, chest. The cause of their appearance can also be diseases such as tuberculosis, poliomyelitis. Hernia of the esophagus in infants manifests itself particularly vividly: the cyanosis of the skin and mucous membrane appears, there is a constant regurgitation, and even vomiting, hiccough. The child is anxious, crying. Disturbance of nutrition leads to a developmental lag, anemia.

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Herniated hernia in pregnancy

Pregnancy is the physiological condition of a woman, in which the hernia of the esophageal opening of the diaphragm often occurs. The likelihood of its appearance is greater in pregnant women over the age of 30 and repeatedly giving birth. The development of hernias, as a rule, is caused by vomiting caused by toxicosis, increasing intrauterine pressure, weakening of the tone of the diaphragm and sphincter between the stomach and esophagus. Symptoms are the same as in another category of patients: heartburn, difficulty swallowing, regurgitation, increased salivation, intensifying when trying to lie down. If in the first trimester of pregnancy, vomiting can be attributed to toxicosis, then in the following period, such manifestations should alert and make people turn to specialists. Anemia in the second half of a child's bearing is an indirect confirmation of the diagnosis.

Stages

There are several degrees of development of hernia of the esophagus, they are caused by the volume of organs penetrating the sternum:

• 1 degree - it corresponds to a slight protrusion of the upper part of the stomach, it just slightly lifts the diaphragm, but the sphincter remains in place. At this stage, the symptoms are either absent or insignificant and are expressed in mild indisposition;
• 2 degree - the lower part of the esophagus and partly the stomach penetrate into the thoracic cavity, the symptoms become more pronounced, the discomfort increases: eructation, heartburn, sometimes there is difficulty in passing food portions;
• 3 degree - the most severe, which can cause serious complications: not only the upper part of the stomach gets to the sternum, but also the doorkeeper, and sometimes even the loops of the small intestine. The patient feels the entire set of symptoms described above.

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Forms

Hernias of the esophagus are classified as follows:

• asymptomatic, in which symptomatology is absent. It is characteristic of small hernias, it is found by chance during other examinations;
• axial or floating (sliding), freely migrates into the thoracic region from the abdominal, when the position of the body changes, manifests itself in the stomach, behind the breastbone, under the shoulder blades, can be given to the neck and jaw. This is the most common type of hernia (about 90% of all cases);
• paraseophageal or fixed, for it it is peculiar to be located on the side of the esophagus; it is unable to move depending on the position of the body;
• mixed, combines the mechanisms of education inherent in the two previous ones;
• congenital, is formed as a result of a defect - a short esophagus.

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Complications and consequences

A hiatal hernia can lead to serious diseases such as:

• ulcer of the hernial part of the stomach;
• chronic gastritis;
• anemia, esophageal and gastric bleeding;
• strangulation, the most unpleasant complication, leading to stretching and even rupture. As a result, fluid accumulates in the pleural area and inflammation of the tissues of the esophageal hernia and other organs occurs, which is very dangerous and can lead to the development of sepsis.

Can a hiatal hernia disappear? It does not go away on its own, but if you follow the rules of nutrition, a healthy lifestyle, and strengthen the abdominal walls, you can live with it if it is in the first two stages of development.

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Diagnostics esophageal hernia

Diagnosis in this case is a serious procedure, the task of which is the correctness of determining the diagnosis necessary for the successful treatment of pathology. Since the clinical picture often resembles the manifestation of other diseases, the examination is thorough and requires tremendous responsibility from the specialist.

Analyzes in the case of a hernia of the esophagus do not carry enough information that determines the diagnosis, therefore, they consist of general blood and urine tests, a biochemical blood test - the usual indicators of the general condition of the body.

In case of bleeding, the level of erythrocytes decreases.

The main task of establishing a diagnosis is the instrumental diagnosis. Diagnostic measures for a hernia of the esophagus consist of:

• X-ray examination using barium contrast (a small dose of ionizing radiation makes it possible to obtain a snapshot);
• gastroscopy - visual identification of the stomach and esophagus by means of a special tube equipped with a video camera;
• esophagomanometry - studies of esophageal motility, allowing to detect even X-ray-negative hernias;
• pH-metry - the establishment of acidity of the stomach;
• MRI and CT of the esophagus and stomach are done only in cases when previous studies did not give a clear clinical picture. In this case, CT shows the physiological state of the organs, and MRI - the chemical structure of the tissues.

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Differential diagnosis

The diverse symptoms of esophageal hernias, often accompanied by various pathologies of the esophagus and other diseases, cause difficulties in differential diagnosis. Hernia can be differentiated from paralysis of the diaphragm, ampulla of the esophagus (phase state during its motor activity), ulcer of its distal section, cardiac pathologies: angina pectoris, ischemic heart disease, myocardial infarction. The diagnosis is specified on the basis of a more in-depth study.

Treatment esophageal hernia

After making a diagnosis, the doctor prescribes a treatment that is appropriate for the specific case. Two methods of patient therapy are practiced: medication and surgery. The patient is prescribed a number of drugs that neutralize the increased acidity of the stomach and coat its mucous membrane. If such treatment does not lead to the expected results, they resort to surgical intervention.

Drug treatment

The following medications are used for drug treatment of diaphragmatic hernia:

• antacids (maalox, almagel, phosphalugel) to neutralize excess hydrochloric acid in the stomach.

Maalox - reduces acidity, adsorbs acid and gases, coats the mucous membrane, has a protective and analgesic effect. It is produced in tablets and suspension, packaged in bags or bottles. Take one to one and a half hours after meals. One or two tablets are placed under the tongue and dissolved. The dose of the suspension is a bag or a tablespoon. Contraindicated in severe kidney pathology. Side effects in the form of phosphorus deficiency are possible;

• prokinetics (domrid, cerucal, motilium) to restore the correct direction of food movement through the digestive tract.

Domrid — exists in tablets and suspension. Promotes increased motility of the esophagus, stomach. Antiemetic. Recommended for taking 20-30 minutes before meals: 1 tablet or a dose measured with a measuring spoon prescribed by a doctor three times a day. If necessary, the dose is increased, but not more than 80 mg per day. Taking the drug can cause anxiety, insomnia, headache, convulsions, bowel movement disorders, heart rhythm disturbances, allergies. Not prescribed in tablets to children under 12 years of age, patients with kidney and liver dysfunction, with gastrointestinal disorders;

• histamine receptor blockers (famotidine, roxatidine, ranitidine) to reduce the production of hydrochloric acid.

Famotidine - tablets, suppress its secretion, reduce the activity of the enzyme pepsin. Prescribed individually, on average one tablet 4 times a day. Can cause dizziness, indigestion, increased fatigue, bronchospasm, arrhythmia. Has contraindications for pregnant women, during lactation, with allergies to components;

• proton pump inhibitors (nolpaza, omeprazole, contraloc), their action is similar to the previous group, but with fewer side effects.

Nolpaza - in tablet form, one tablet is swallowed whole in the morning before meals, the course of treatment lasts 2-4 weeks. If necessary, 2 pieces can be prescribed. In most cases, the drug is well tolerated, but nausea, excess liver enzymes, edema, and visual impairment may occasionally occur. It has contraindications in case of individual intolerance, neurotic dyspepsia. It is not prescribed to under 18 years of age, pregnant and lactating women due to the lack of research on the effect of the drug on this category;

• Bile acids (urochol, ursofalk) neutralize bile acids thrown into the stomach.

Urohol - drops, a herbal preparation that increases bile secretion and relieves inflammation. Before meals, three times a day, 10-20 drops are dripped into a small amount of water and drunk. Not recommended for children under 12, pregnant or nursing mothers. Side effects include nausea, vomiting, and allergic reactions.

Vitamins

Esophageal hernia requires a balanced diet rich in vitamins and microelements. Foods rich in vitamin A promote the production of glycoproteins that neutralize the aggressive effects of hydrochloric acid in gastric juice, and therefore help eliminate heartburn. Butter, fish, liver, carrots, dark greens contain this vitamin and will be useful for such a diagnosis.

Diet

Treatment is more effective if patients simultaneously adhere to a diet. It is gentle in nature, its essence is to eliminate irritation of the mucous membrane, relieve pressure inside the peritoneum due to a small volume of food consumed, and exclude coarse food. The nutritional features are the same as for gastritis with high acidity, esophagitis: it should be frequent, in small portions, so that food can freely pass through the digestive tract, be absorbed and not return back. Temperature contrasts, such as very hot or cold food, are unacceptable. The diet of a patient with an esophageal hernia includes the following products: dried buns and bread, mucous soups (without meat, fish, mushrooms, vegetables), porridge, pasta, dairy products. Meals should be cooked by boiling, baking or steaming. Use sunflower and butter, eliminate foods with coarse fiber that increase gas formation: cabbage, mushrooms, legumes, and fatty foods. You can eat a fresh cucumber, after peeling it. What should you not eat? Do not consume alcohol, sour juices, fatty, spicy, peppery foods, or marinades, as they increase acidity. Fasting for a hiatal hernia is not recommended.

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Nutrition after hiatal hernia surgery

Nutrition after esophageal hernia surgery is no different from the diet for other abdominal surgeries. Depending on the severity of the surgery, feeding through a tube is even possible in the first days. If all goes well, it is permissible to drink only 1-1.5 glasses of water on the first day. On the second day, pureed food is recommended in the form of low-calorie puree soups, slimy rice broth, weak meat broth. You can drink rosehip infusion, jelly, mineral water without gas or plain water. Then, in small portions, pureed porridges, steamed amelets, soufflé from dietary minced meat, croutons from white bread of your own making are added, increasing the daily caloric content to 1500 kcal. In the following six months, it is necessary to adhere to diet No. 1, intended for patients with gastric ulcer, duodenal ulcer, gastritis with high acidity.

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Diet menu for the day

The diet menu for the day may be as follows:

• breakfast: milk porridge (rice, buckwheat, oatmeal, semolina), 2 soft-boiled eggs, tea with milk;
• 2nd breakfast: low-fat cottage cheese, sweet berry jelly;
• lunch: vegetable soup, steamed meatballs with mashed potatoes, baked apple;
• afternoon snack: rosehip infusion, crackers;
• dinner: boiled fish, slimy rice side dish, tea with milk, biscuits;
• 2 hours before bed: a glass of warm milk.

Recipes

Some recipes for preparing dietary dishes:

1. puree soup: cut potatoes, carrots, zucchini into cubes, separate cauliflower into florets, add water, add a little salt and cook until done. Grind with a blender, add low-fat cream or butter, eat warm;
2. steamed cutlets: chicken, veal (in equal parts), some oatmeal, previously soaked in milk, grind, add salt, add a raw egg and form cutlets. Cook on steam;
3. lazy vareniki: combine cottage cheese, eggs (2 eggs per 0.5 kg of cottage cheese), sugar. Add flour until a fairly thick mass is obtained. Roll into a sausage, cut into 1.5 cm thick strips with a knife, boil in lightly salted water. Eat, pour fresh low-fat sour cream;
4. Baked apples: make a depression on top of the fruit, add a teaspoon of honey and bake in the oven.

Physiotherapy treatment

Physiotherapeutic treatment involves hydrotherapy, the use of amplipulse, electrosleep, information-wave therapy, short-pulse electrical neurostimulation. There are also special exercises to strengthen and relax the muscles of the anterior abdominal wall. The exercises can be as follows:

• lying on the right side (head and shoulders raised relative to the body, on a pillow) inflate the stomach when inhaling, relax when exhaling. After a week, draw in the stomach when exhaling;
• kneeling, inhale, bend to the sides, exhale in the starting position;
• lying on your back, perform body turns while inhaling air.

Folk remedies

Folk remedies for the treatment of hernias most often consist of the use of medicinal herbs that help eliminate the main symptoms of the disease:

• For heartburn, combine licorice root and orange peels, pour boiling water over them, let it brew for 30 minutes, take after meals. Gentian tea, flax seed infusion, juice from grated carrots and raw potatoes help;

• for belching, prepare an infusion of rowan flowers, blackberry leaves, cranberry juice, add honey and aloe juice;
• for bloating, an effective remedy is dill water (1 tablespoon of seeds per half a liter of boiling water, leave for 3 hours, take 100g 15 minutes before meals), infusions of caraway, chamomile flowers, dandelion; brew herbal infusions of yarrow, immortelle, St. John's wort. Another collection: peppermint, fennel fruits and valerian root;
• Infusions of senna leaves, buckthorn, rhubarb root, garden dill, and field horsetail will help with constipation.

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Surgical treatment

Surgery is indicated only in extreme cases, when either conservative treatment is ineffective, or the hernia is large, or there are life-threatening complications, etc. The choice of surgical solution to the problem depends on the nature of the disease. Based on the cause of the hernia and its type, the operation may consist of:

• in suturing the esophageal opening of the diaphragm to a normal diameter of 4 cm;
• formation of a “cuff” for the esophagus from the walls of the stomach;
• creation of an artificial valve in the upper part of the stomach;
• strengthening the ligament between the diaphragm and the esophagus.

The emergence of the laparoscopic method in the 90s of the last century made it possible to perform surgical interventions with minimal harm to the patient's health. If after abdominal surgery the rehabilitation period is almost 3 months, then after laparoscopy the patient gets up on the 2-3 day, and after 3 weeks starts working.

Prevention

Prevention of esophageal hernia consists of strengthening the abdominal muscles, treating constipation, avoiding lifting heavy weights, and severe coughing. Timely therapy of gastritis, duodenitis, peptic ulcer, chronic cholecystitis, and pancreatitis is important. Giving up bad habits is also important for preventing pathology.

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Forecast

The prognosis of the development of the disease is as follows: there is a real probability of complications in the form of an ulcer or stenosis of the esophagus, bleeding, infringement, endangering life. Relapses after surgery are extremely rare.

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