Hiatus hernia

The term hiatus hernia, also known as a diaphragmatic hernia, is used when parts of the stomach are displaced from the abdominal cavity into the chest cavity through a naturally occurring gap in the diaphragm. Hence, strictly speaking, a diaphragmatic hernia is not an intestinal hernia.
ICD codes for this diseases: K44, K45, K46

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Article overview

A diaphragmatic hernia is not an intestinal hernia in the proper sense since the gap is a normal anatomic structure, namely the so-called hiatus oesophageus. This is the opening in the diaphragm, through which the esophagus (food pipe) reaches the stomach in the abdominal cavity. Since a hiatus hernia, unlike an inguinal hernia or an umbilical hernia, for example, does not protrude outward from the inside of the body, it is counted among the internal hernias.

Forms of diaphragmatic hernia

In principle, three different forms of diaphragmatic hernia can be distinguished: malformation of the cardia, axial hernia (sliding hernia) and paraesophageal hiatus hernia.

Malformation of the cardia represents the mildest form of hiatus hernia. Here, the esophagus enters the stomach at a more obtuse angle than the so-called esophagogastric angle or angle of His because the ligaments, by which the stomach is attached to the diaphragm, are loosened. Symptoms of malformation of the cardia only appear in the rarest of cases.

In a paraesophageal hiatus hernia, parts of the stomach near the esophagus slide into the chest cavity from below through the hiatus oesophageus, which can lead to a constriction of the stomach and, in extreme cases, to so-called upside-down stomach, where the entire stomach is located above the diaphragm.

In an axial hernia, which is also called a sliding hernia, the upper part of the stomach, just as in paraesophageal hernia, slides up into the chest cavity through the hiatus oesophageus. As a result, the function of the so-called esophageal sphincter, that is, the closing muscle which closes the esophagus, is also disrupted so that the stomach contents can flow back into the esophagus. This is also known as reflux disease. At a rate of 90 percent, axial hernia represents the most frequent form of hiatus hernia.

Frequency of diaphragmatic hernia

Hiatus hernia represents the most frequent form of internal hernia. Here, men are more frequently affected than women. Hence, approximately twice as many men over the age of fifty suffer from a diaphragmatic hernia than women. Overall, the likelihood of suffering from a hiatus hernia increases with age.

Causes and risk factors for diaphragmatic hernia

A diaphragmatic hernia can be either congenital or acquired. An acquired diaphragmatic hernia occurs due to an enlargement or stretching of the so-called hiatus oesophageus. The enlargement of this naturally occurring gap in the diaphragm is most commonly caused by a general weakness of the connective tissue of the diaphragm in combination with a more prolonged increase in the pressure in the abdominal cavity.

For this reason, above all, people who are severely overweight have an increased risk of suffering from a hiatus hernia. Further risk factors for the occurrence of a diaphragmatic hernia are pregnancy, advanced age and the male gender. Abdominal surgery can also favor the occurrence of a hiatus hernia.

Symptoms of diaphragmatic hernia

A hiatus hernia may cause symptoms, but not necessarily so. The nature of the symptoms depends on the form of the diaphragmatic hernia. Possible symptoms which can appear with a hiatus hernia include heartburn, anemia, a feeling of fullness, belching, difficulty in swallowing and apnea. A hiatus hernia may also cause gastric pain or pain in the upper abdomen or chest, for example, when parts of the stomach are incarcerated in the gap in the diaphragm.

Diagnosis of diaphragmatic hernia

In order to diagnose a diaphragmatic hernia, the physician will initially ask the patient about his symptoms in the course of taking the history. If the patient reports symptoms here such as heartburn, then this may indicate the presence of reflux disease and a hiatus hernia. The unambiguous diagnosis of a diaphragmatic hernia, however, is only possible by means of imaging examination, such as an upper gastrointestinal x-ray series, an endoscopy of the esophagus, magnetic resonance imaging or computed tomography.

Treatment of diaphragmatic hernia

Milder symptoms such as heartburn can initially be treated with medication, as a rule. If the hiatus hernia affects vitally important functions such as the respiration or if more severe symptoms appear with the risk of damage to organs, diaphragmatic hernia surgery must be performed within the framework of hernia surgery.

Here, with so-called fundoplication (using either the Nissen and Rosetti technique or the Toupet technique), so-called gastropexy or fundopexy and so-called hiatoplasty, a variety of surgical techniques are available for the treatment of a hiatus hernia. In a fundoplication, a cuff is formed from portions of the stomach and positioned around the lower part of the esophagus. In a gastropexy, (fundopexy), the stomach is moved into its normal position and firmly sutured to the anterior wall of the abdomen and in a hiatoplasty, the gap in the diaphragm (hiatus oesophageus) is sutured more tightly.

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