Axial hernia of the esophagus

According to the definitions adopted in gastroenterology, axial is axially located, and axial esophageal hernia means that the short distal part of the esophagus in the abdominal cavity with some part of the stomach moves up, slips through the esophageal opening of the diaphragm and ends up in the chest - with eventration that is, protrusion into the posterior 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 code K44.

Epidemiology

The exact statistics of axial hernia of the esophagus is unknown, since most studies take into account only those patients who showed its symptoms. Although out of ten diagnosed hernias of the esophagus, nine account for axial hiatus hernia.

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

In 9% of diagnosed cases, the hernia is caused by 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.

[1], [2], [3]

Causes of the axial hernia of the esophagus

This pathology has other names: sliding axial hernia of the esophageal orifice of the diaphragm or simply sliding esophageal, axial hiatal hernia (hiatus oesophageus - esophageal opening), as well as axial cardiac hernia of the esophageal opening of the diaphragm, as the protrusion changes the anatomical position of the cardia (cardia).

This is a hole in the upper tubular part of the stomach that has a thin muscular ring, called a gastroesophageal, lower esophageal or cardiac sphincter (ostium cardiacum), which provides for unilateral movement of swallowed food (in the stomach) and prevents its “reverse motion”. And decisive in the etiology of the sliding axial hernia of the esophagus recognized dysfunction of the sphincter - the failure of the cardia.

Listing the possible causes of the axial sliding hernia of the esophagus, experts note that the main problems are the expansion of the esophageal opening of the diaphragm 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, in some cases a congenital abnormality is observed - idiopathic reduction in the length of the esophagus, systemic autoimmune diseases of the connective tissue, in particular esophageal scleroderma, as well as the chronic form of  gastroesophageal reflux disease  (GERD) can lead to shortening . In the latter case, according to experts, the esophagus tube becomes slightly shorter due to the reflex contraction of the longitudinal smooth muscle fibers of its shell under the constant influence of gastric acid.

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

[4],

Risk factors

It is necessary to take into account such risk factors for the development of axial hernia of the esophagus, such as:

• abdominal obesity, accumulation of fluid in the abdominal cavity, severe chronic cough of various etiologies, frequent vomiting, esophagitis, excessive straining with constipation and weight lifting , pregnancy and difficult labor (causing an increase in pressure in the abdominal cavity);
• elderly age;
• genetic predisposition; ,
• diseases that reduce 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 (eg, anticholinergic, containing theophylline or progesterone).

[5], [6]

Pathogenesis

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

The part of the esophagus, which is below the diaphragm (abdominal section) has a length of from 20 to 40 mm (average length is 25 mm). But if - due to the anatomical features - it is shorter, then after eating and increasing the pressure in the stomach, the probability of "pushing" the abdominal esophagus through the hiatus into the area above the diaphragm increases many times. Chest 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).

Axial sliding hernia of the esophageal opening of the diaphragm also occurs due to the expansion of the muscle tunnel of the hiatus itself and / or due to the 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 one holds the cardiac part of the stomach at the lower surface of the diaphragm on the cardiac cavity of the stomach - providing independent movement of the diaphragm and esophagus during breathing and swallowing.

All fascia and ligaments are made up of connective tissue (fibroblasts, collagen fibers and elastin), but as they age, the volume of collagen and elastin fibers decreases, so that the resistance and elasticity of the esophageal ligament decreases. With a gradual increase in hernia that has slipped through the esophageal opening above the diaphragm, the ligament stretches, displacing the same area where the esophagus passes into the stomach (gastroesophageal junction).

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 also associated with the violation of the position of the so-called diaphragmatic-esophageal membrane, which is a crease of the 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 cardia deficiency, already mentioned above.

Every organ in our body has its place. And violations of the location of the organs often become the cause of the deterioration of their functionality, which can not but affect the human well-being. The same happens with hernia of the esophageal opening of the diaphragm.

[7], [8], [9], [10], [11]

Axial or hiatal?

Hernia of the esophagus is a pathology characterized by the migration of gastrointestinal organs through the esophageal opening of the diaphragm to the region of the sternum. The shift of organs can be done in two ways:

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

In some cases, a non-standard situation can also be observed, where the axial type of the esophagus and stomach is displaced, but intestinal loops also penetrate the hole. 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, which other organs of the upper body cannot, is of limited size. Its diameter is just over 2.5 cm. The size of the opening is enough to allow the esophagus to freely pass through it, and the food previously minced in the mouth can move freely in the organ lumen. If the diaphragmatic opening is enlarged due to some of the reasons, not only the esophageal tube, but also the stomach or a separate part of it, can slip into it as the intra-abdominal pressure rises.

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 located in the immediate vicinity of the esophageal opening (Morozov-Savvina ligament), and reducing the diaphragm muscle tone in the area of the gap. These are interrelated situations, more characteristic of age-related changes in the human body, when metabolism slows down, and muscular and connective tissues lose their strength and ability to withstand stress.

Weakening of the muscles of the diaphragm and ligamentous apparatus also contributes to bad habits, among which are the habit of constantly overeating, excess weight, injuries to the muscle plate separating the chest and abdominal cavity, hypodynamia, leading to atrophy of the musculoskeletal system. The weakening of the ligament leads to an increase in the diameter of the hole, which allows the esophagus and the stomach to move upward relative to it.

But the above points 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 orifice. Particularly dangerous situations when the increased pressure in the peritoneum is observed on a permanent basis or the situation recurs regularly.

This is possible with diseases of the stomach and intestines, accompanied by increased gas formation and chronic constipation, lifting and carrying weights, high physical exertion, prolonged straining cough, characteristic, for example, for bronchial obstruction. With the increase in intra-abdominal pressure due to the growth of the uterus, pregnant women are also confronted, and the hernia of the esophagus developing in 2-3 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 the stomach relative to the orifice of the diaphragm can be triggered by anomalies of 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 may also be caused by an inflammatory process in the tissues of the organ or chronic spasm of the esophagus walls.

Inflammation can be triggered 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 that do not have sufficient protection, is regularly thrown into the esophagus. And sometimes the inflammatory process extends to the esophagus from the nearby organs of the digestive system: the stomach, intestines, pancreas, liver, because they are all interconnected. Therefore, the presence of any diseases of the gastrointestinal tract associated with the inflammatory process or a violation of their motility, can be considered a risk factor for the development of axial hernia of the esophagus.

Long-lasting inflammation in the esophagus is fraught with the replacement of the affected areas with inelastic fibrous tissue, which, as it were, tightens the organ and thereby reduces its length, as a result of which the gastrointestinal fistula gradually shifts upward, dragging the cardiac section of the stomach.

As you can see, all these situations are quite common, so it is not surprising that hernia of the esophagus in its popularity is gradually approaching gastritis, gastric ulcer and cholecystitis, recognized leaders among gastrointestinal diseases. Moreover, among the 2 types of hernia of the esophagus, the axial takes the leading place. Only about 10% of patients diagnosed with hernia of the esophagus have paraesophageal or mixed form. The remaining 90% comes from a hiatus hernia.

[12]

Symptoms of the axial hernia of the esophagus

With a small axial hernia of the esophagus, any symptoms may be absent. And the first signs of a sliding axial hernia at the initial stage of pathology development can be manifested by sensations of an overflowing stomach and heaviness in the subcostal area of the abdomen, as well as frequent heartburn .

Also note acidic regurgitation, coughing, asthma-like attacks of shortness of breath, hoarseness, difficulty in swallowing (afagiya, less often - dysphagia).

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

The degrees of the axial sliding hernia are distinguished by the fact which anatomical structures move into the thoracic cavity from the abdominal. If this is only the distal (abdominal) part of the esophagus (the stomach is pulled close to the diaphragm), then an axial esophageal hernia of 1 degree is diagnosed. When the lower esophageal sphincter slips through the hiatus and localizes the gastroesophageal junction in it, axial hernia of the esophagus 2 degrees is determined, and when moving and protruding into the mediastinum also of the bottom or cardiac regions of the stomach, axial hernia of the esophagus 3 degrees.

It is clear that the higher the degree of hernia, the greater the patient's complaints - from discomfort in the upper abdominal cavity, heartburn and shortness of breath down to pronounced epigastric pain and rapid heartbeat - due to irritation of the vagus nerve (nervus  vagus ) passing through the esophageal opening aperture.

Stages

Normally, the esophago-gastric fistula (the junction of the lower end of the esophagus and the cardia of the stomach) is 2-3 cm below the aperture of the diaphragm, and the body of the stomach is located to the left of the imaginary axis and rests against the left dome of the diaphragm. In axial hernia of the esophagus, the lower opening of the esophagus, as well as successively different sections of the stomach, starting from the cardiac one, can be displaced into the dilated opening.

The larger part of the stomach is displaced into the chest cavity, the greater is the formed hernia, which is presented by him. And with an increase in the size of the hernia, the severity of the symptoms of the disease also increases.

Axial hernia of the esophagus is a progressive disease in which there is a 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 hole becomes, the larger part of the stomach can slip into it. In the area of the opening, the organ is somewhat compressed, forming a peculiar bag of a larger or smaller size above the diaphragm. It is this bag in the thoracic region and is called a hernia.

In progressive pathology, there are usually several degrees or stages of development. Axial hernia has three of them. Let's try to figure out how they differ, what symptoms are characterized and what danger they pose.

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

At the first stage of the pathology, abnormalities in the work of the stomach associated with its compression are not observed. The patient may feel only a little discomfort with a deep breath, therefore, is unlikely to rush to the doctor for examination. The disease can be detected by chance 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 on the background of the already existing inflammatory pathologies of the gastrointestinal tract or in violation of the motility of the stomach and intestines, as a result of which a reflux disease develops.

Reflux with his characteristic symptoms at this stage of the pathology does not develop (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 grade 2 esophagus is still considered a mild form of the disease, although, due to the expansion of the esophageal opening, the distal esophagus and the cardial section of the stomach (cardia and upper organ) can already penetrate into it. However, squeezing the stomach in the diaphragmatic opening is already beginning to affect its performance, so the matter is not limited to mere discomfort in the area of epigastia.

The patient has aching pain behind the sternum, something resembling cardiological and spreading in the back between the shoulder blades, begins to torment heartburn (a burning sensation along the esophagus), belching (more often with air, but with regurgitation of the muscles of the abdomen or tilts, food regurgitation appears). In the mouth may appear sour or bitter taste, which hardly disappears after drinking water or jamming sweet.

Nausea with axial hernia appears rarely in contrast to reflux, provoked by squeezing the stomach and a violation of its motility. The ingress of partially digested food with gastric enzymes into the esophagus provokes inflammation of the walls. And if at first pains arose only when straining, lifting weights and overeating, now they can appear in inclinations and in the horizontal position of the body, and then without any particular reason.

Impaired gastric motility at stage 2 of the disease is fraught with digestive disorders, when diarrhea and constipation alternate. Problem defecation causes regular straining and tension of the abdominal muscles with an increase in pressure inside the abdominal cavity. All this aggravates the situation and contributes to the growth of a hernia. The situation is exacerbated by the development of inflammation in the esophagus caused by reflux, although serious complications are not discussed so far.

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

Since this stage of the disease was preceded by 2 others, which made their undesirable contribution to the state and functioning of the stomach and esophagus, the symptoms of the disease not only do not subside, but become even more pronounced. Grade 3 of the pathology of the esophagus is typical for grade 3 pathology: heartburn triggered by reflux (and at this stage almost all patients complain of it), belching, chest and abdominal pain, hiccups, dysphagia.

Casting gastric contents provokes a burning sensation along the esophageal tube, associated with the irritation of its walls with digestive enzymes. The longer and more regularly the food is thrown into the esophagus, the more likely it is the development of inflammatory and degenerative changes in the organ, causing mucosal replacement with inelastic fibrous tissue, which, under stress, can burst with the formation of ulcers and hemorrhages. This pathological condition is called reflux esophagitis, which is considered a frequent complication of the hernia of the esophagus.

Scar formation on the walls of the esophagus reduces its lumen, causing stenosis of the organ, which is considered a chronic condition in contrast to muscle spasm 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 weight loss, deficiency of vitamins and minerals. Along with bleeding, this provokes the development of iron deficiency anemia, beriberi, exhaustion.

When the gastric contents are thrown into the oral cavity, the walls of the esophagus, but also of the pharynx, become inflamed, as a result of which the patient's voice changes, becoming less resonant, hoarse, and deaf.

Hiccup, which with hiatus hernia of the esophagus differs in enviable duration and intensity, is triggered by the compression of the phrenic nerve by the growing hernia. Irritation of the nerve endings causes uncontrolled contractions of the diaphragm with the ejection of air and specific sounds. In addition to the unpleasant sensations, this symptom carries no danger, but in some situations it can cause psychological discomfort.

Displacement in the diaphragmatic orifice of the esophagus, stomach, and intestines is accompanied by pain sensations, which gradually turn from aching ones into burning ones. Axial hernia of the esophagus has another name - sliding, because when you change the position of the body, increasing or decreasing the intra-abdominal pressure, it can move up or down. Her movement is just accompanied by increased 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 intestine.

Pain can significantly impair the quality of life of patients. Their reinforcement is marked in a horizontal position, which does not allow patients to rest normally at night, causing frequent awakenings and problems with falling asleep. Lack of night rest and chronic pain have a negative effect on the psycho-emotional state of the patients, their communicative qualities, and work capacity.

Increased intragastric pressure during a hernia of the esophagus as a result of its compression by the diaphragmatic opening and the chest organs stimulates a sharp release of air swallowed during a meal. This process is called burping. In a healthy person, the air comes out slowly and gradually, and with increased pressure in the stomach, it is abrupt, with effort and accompanied by a loud, unpleasant sound.

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

In patients with grade 3 hernia of the esophagus more often regurgitation occurs, i.e. Spitting up food without first gagging. When you change the position of the body or during physical exertion 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 with him special bags for spitting “return”. From the side it looks depressing and can cause already strong psychological discomfort, isolation, reduced self-esteem, restriction of social activity.

Another problem peculiar to axial hernia of the esophagus is esophageal dysphagia or impaired swallowing in the lower esophageal sphincter. Such a symptom can be triggered by a long-lasting reflux disease, irritation and strictures of the esophagus or muscle spasm of the organ as a result of the same irritation, but already the nerve endings responsible for the contractile movements of the esophageal tube.

The more pronounced the manifestation of stenosis, the harder it is for the patient to eat. First, problems arise when eating solid foods, then difficulties begin with the intake of semi-liquid and liquid foods. And everything can end with the impossibility of drinking water or swallowing saliva due to severe stenosis, which requires prompt intervention and restoration of communication between the esophagus and the stomach.

In dysphagia, the patient's complaints are reduced to a feeling of coma in the throat and discomfort in the mediastinum area. Drinking fluids does not solve the problem. As the lumen narrows, it is necessary to change the patient's diet, diet, volume of servings, which is considered as ancillary measures. If nothing is done, the lumen of the esophagus due to chronic inflammation will decrease, which indirectly leads to the 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. And because of the mobility of the organs inside the diaphragmatic orifice, the symptoms may subside or reappear with physical exertion and a change in body position. But there is no reason to expect that the organs will return to their normal position and stay there forever, therefore, when the first signs of gastrointestinal tract pathology appear, you need to consult a gastroenterologist for advice, diagnostics, and prescription of treatment corresponding to the degree of development of the disease.

[13], [14], [15], [16], [17]

Forms

In the absence of a single classification, such forms or types of axial hernia of the esophagus are distinguished, such as congenital (arising from the initially increased size of hiatus or short esophagus) and acquired; unfixed (spontaneously reset with the vertical position of the body) and fixed (in rare cases).

Proceeding from the part of the stomach protruding above the diaphragm, an axial cardiac hernia of the esophageal opening of the diaphragm, cardial fundus, subtotal and total gastric are also determined.

[18], [19]

Complications and consequences

Many gastroenterologists claim that there is no such complication as incarceration with a sliding axial hernia of the esophagus, since its hernial ring is the pathologically extended natural anatomical opening of the diaphragm.

But in rare cases, this is possible: with defects in posture or spinal curvature. 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 manifested:  erosion of the esophagus  and ulcerative esophagitis (with pain and burning in the sternum and the threat of perforation of the esophagus); prolapse (prolapse) in the esophagus of the mucous membrane of the stomach; latent 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. ,

[20], [21], [22]

Diagnostics of the axial hernia of the esophagus

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

Instrumental diagnostics is carried out by: fluoroscopy (with barium) and ultrasonography of the esophagus and stomach, their endoscopic examination and esophageal (esophageal) manometry, CT . With cardialgia, an ECG is required.

[23],

Differential diagnosis

Differential diagnosis, given the similarity of symptoms, aims not to take over the axial sliding hernia: a superficial gastritis, inflammation of the mucous membrane of the duodenum - duodenitis, diverticulitis of the esophagus and dilatation of its veins, supradiaphragmatic expansion ampoules esophageal, coronary artery disease, angina pectoris, and others.

[24], [25]

Treatment of the axial hernia of the esophagus

It is not worthwhile to dwell on the fact that any disease requires adequate treatment, and the sooner it is started, the easier it is to overcome the disease. This has been said to us many times already, and the hernia of the esophagus is an excellent confirmation of this. A doctor's prescription for this disease strictly depends on the stage of development of the pathology. Their volume increases from changing the diet at the initial stage of the disease, to surgery at the last, when there is a high risk of complications that threaten the health and life of the patient.

For the treatment of axial hernia of the esophagus 1 degree, in which there are no symptoms of malaise or they are expressed slightly, it is usually sufficient to correct the patient’s lifestyle. The patient is recommended to avoid sudden body tilting, weight lifting, to rest more, practice measured physical activity, which will contribute to the normalization of the gastrointestinal tract, prevent constipation, improve metabolism.

Hypodynamia in this pathology will only complicate the course of the disease, so every day you need to walk, ride a bike, do jogging. Opportunities for sports training should be discussed with a doctor, but heavy sports with hernia of the esophagus are clearly contraindicated.

Special attention should be paid to the nutrition of the patient. Diet for axial hernia of the esophagus implies restriction of the use of heavy and acute food irritating the mucous membrane of the digestive tract, including alcohol and soda. The latter, along with the hard-to-digest fatty foods, causes flatulence and an increase in intra-abdominal pressure, which is very undesirable for this disease.

Meals should be complete, rich in vitamins and microelements, but at the same time light, which will facilitate the unloading of the digestive organs and timely trouble-free emptying of the intestines without straining. Recommended fractional meals with a frequency of eating up to 6 times a day. Portions should be sufficient for saturation, but not leading to overeating. If you have excess weight, you will have to deal with it through moderate physical activity and reducing the calorie content of servings.

Drug therapy in the absence of symptoms of reflux disease and severe pain is not carried out. However, if the patient suffers from constipation or has digestive problems caused by concomitant diseases, you will have to drink regularly laxatives, enzyme preparations and other necessary medicines that will make digestion comfortable.

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

• antacidy ("Fosfalugel", "Almagel", "Renni", "Maaloks", "Gastal"),
• proton blockers (Omez, Omeprazole, Pantoprazole, Nexikum),
• inhibitors of histamine receptors used in gastroenterology ("Ranitidine", "Famotidine", "Rhinitis", "Quatemal", "Famatel").

To normalize the motility of the stomach and intestines, which helps to reduce the frequency of reflux episodes, prescribe drugs from the category of prokinetics: “Domperidone”, “meoclopramide”, “Zerakal”, “Motillium”, “Primer”, etc. Digestive chain and timely emptying of the intestines, which makes it possible to refuse to take laxatives.

With reflux disease, all the above-described requirements for lifestyle are particularly relevant. And from the complex of physical therapy such patients should pay special attention to breathing exercises that 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 2 degrees, when symptoms of reflux disease manifest themselves to varying degrees, the use of drugs that improve the work of the digestive system, reduce the acidity of gastric juice and reduce its secretion, becomes even more relevant.

Dietary requirements are also becoming more stringent, from which all foods and dishes that stimulate the synthesis of digestive enzymes and increase the production of gastric juice and its acidity should be excluded. In general, a diet with 1 and 2 degrees of pathology practically does not differ.

Medical therapy corresponds to that which is carried out in case of reflux disease. It involves taking drugs 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 (shown during esophageal spasm or susceptibility to it).

Both with the first and second degrees of axial hernia of the esophagus, the use of alternative recipes with an appropriate mechanism of action is allowed, but the possibilities and safety of their use must be discussed with the doctor.

The physical activity of the patient remains at the same level. Weight lifting becomes extremely undesirable, as well as any excessive tension of the abdominal muscles, provoking an increase in intra-abdominal pressure. Exercise exercises should be carried out regularly and preferably under the supervision of a specialist (at least for the first time).

Axial hernia of the esophagus Grade 3 before the development of complications is treated by analogy with the second. 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 during stenosis, reflux esophagitis, the development or progression of gastric ulcer and duodenal ulcer, bleeding from the gastrointestinal tract, impaired heart function, phrenopyloric syndrome, etc. Surgical treatment combining laparoscopic surgery with plastic surgery of the tissues of the diaphragmatic orifice.

Regardless of the type of operation performed, the patient is prescribed a diet, drug treatment, lifestyle correction, exercise therapy. The probability of recurrence of the disease depends on it, because the axial hernia of the esophagus in severe degree implies a number of serious violations in the work of the digestive system and ligamentous apparatus, for which correction only surgical intervention is not enough.

There is no need to treat asymptomatic (accidentally identified) axial hernia of the esophageal opening of the diaphragm.

Treatment of axial hernia of the esophagus is symptomatic in the majority of cases of complaints.

The relief of the symptoms of the pathology is given by such drugs as antacids -  Almagel, Fosfalyugel,  Gastal  , etc.; histamine H2 receptor blockers (Gastrosidine, Famotidine, Ranitidine).

Dosage, contraindications and side effects, see -  Heartburn pills

Drugs such as Pantoprazole,  Omeprazole, Rabifin, etc., have been found to be more effective in reducing gastric acid secretion, but they need to 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 medical therapy, surgical treatment is carried out in the form of operations such as gastrocardiopexy (according to Hill’s method) and laparoscopic fundoplication (according to Nissen’s method). Details in the publication -  Diaphragmatic hernia

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

The doctor recommended exclusion from the diet of  foods that increase acidity  and prescribed a diet for axial hernia. Maximum take into account the necessary changes in nutrition  Diet for heartburn, as well as  Diet for esophagitis

Prevention

In order to prevent this pathology, any factors that can increase intra-abdominal pressure should be avoided, first of all, to normalize body weight and to establish a regular bowel movement.

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

[26], [27]

Forecast

Is full recovery possible in the presence of axial hernia of the esophagus? Unfortunately, it is a chronic recurrent disease. The overall outlook for life is positive; symptomatic treatment and surgery relieves most patients, although some symptoms will continue to show.

[28], [29], [30], [31], [32], [33]