The diaphragmatic hernia / hiatal hernia

The diaphragm is a dome-shaped muscle and tendon tissue that separates the abdominal cavity from the chest cavity. The oesophagus passes through the diaphragm. At this point of passage, the muscle tissue is somewhat looser and hiatal hernias can develop more easily here. In this case, part of the stomach is pushed upwards through this opening in the diaphragm into the chest cavity. Hiatal hernias can be congenital or acquired. Risk factors that favour hiatal hernias are obesity, a low-fibre diet, weakness of the connective tissue, pregnancy and age.

A hiatal hernia is often diagnosed by chance during a gastroscopy. However, diagnosis is also possible by means of X-rays, before which the patient is given a mash with contrast medium. Only about 10% of diaphragmatic hernias cause symptoms.

There are different forms of hiatal hernias:

The axial sliding hernia (type I)

An axial hiatal sliding hernia is relatively common, in which the uppermost part of the stomach is pushed through the oesophageal slit and the diaphragm into the chest cavity. The hiatus can often slide back and forth between the abdominal and thoracic cavity. Reflux disease usually occurs concomitantly.

The paraoesophageal hernia (type II)

Much rarer, in about 10 % of cases, is the parasoesophageal hernia. In this case, a substantial part of the stomach slides next to the oesophagus into the chest cavity, but often the entrance to the stomach remains below the diaphragm, unlike in axial sliding hernias. The risk of entrapment is greater than with axial sliding hernias. About 70 to 80 % of paraoesophageal hernias are due to a congenital defect of the diaphragm. In this case, the oesophagus and the aorta pass through the same large opening in the diaphragm instead of through two separate ones.

Mixed forms of axial and paraoesophageal hernias (type III)

In this case the disease usually starts with an axial sliding hernia, with more and more stomach sections then shifting laterally next to the oesophagus into the chest cavity over time.

Upside-down Stomach

In paraoesophageal hernia, when the stomach slides completely into the chest cavity and lies “upside down” in the chest cavity, it is called an upside-down stomach.

With an axial sliding hernia, there are often no symptoms. With paraoesophageal hernias, the patient finds it increasingly difficult to swallow. One third of type II hiatal hernias are recognised due to anaemia, the remaining two thirds are manifested by swallowing difficulties.
In diaphragmatic hernias, where large portions of the abdominal organs are forced into the hernia sac, the heart and lungs are constricted in the chest cavity and shortness of breath and circulatory problems may occur.

• Heartburn / reflux
• Air bursting or acid bursting
• Difficulty swallowing
• Feeling of fullness
• Vomiting
• Flatulence
• Chronic cough may occur in addition
• Pain behind the breastbone or in the upper abdomen
• After eating, feeling of pressure in the heart area and circulatory problems
• Chronic anaemia
• Oesophagitis

CAUTION: If you experience severe pain, bloating and retching, it could be an incarcerated hernia. Call us immediately or go to the nearest hospital emergency ward!

The treatment depends on the symptoms and the extent of the hernia. Small diaphragmatic hernias cause little discomfort. Here, acid-inhibiting medicines are often used against the heartburn, but this only combats the symptoms. For larger hernias, especially if there is a risk of incarceration, surgery is performed. Otherwise, bleeding ulcers in the stomach, pain or the inability to eat can develop.

Since hiatal hernias promote the backflow of stomach acid into the oesophagus, the stomach (gastritis) and the oesophagus can become chronically inflamed (reflux oesophagitis) as a result. If this condition persists for years, the chronic inflammation can possibly develop into oesophageal cancer.

If you suffer from a hiatal hernia, you should not eat too large portions at one time. It is better to eat smaller meals several times a day. Patients should avoid acidic drinks such as sweet drinks or orange juice. Alcohol, coffee, chocolate and very acidic, spicy or fatty foods also have negative effects. The consumption of painkillers should be kept to a minimum, as these can also cause discomfort in the stomach and oesophagus. You should not eat right before going to bed. This reduces the risk of heartburn and reflux disease. Losing weight, getting enough exercise and avoiding clothes that are too tight also help. Sleeping with an elevated headboard helps to reduce heartburn, but also prevents the organs from sliding back up into the chest if you have a hiatal hernia.

If more than 30% of the stomach has slipped into the chest, surgery should be performed. Proper positioning of the stomach and closing the hole in the diaphragm can usually be done minimally invasively. Sometimes surgeons attach the stomach to the anterior abdominal wall or to a point on the diaphragm. A mesh can be used for further stabilisation.

With a minimally invasive procedure, 3-4 days in hospital are to be expected. Before solid food can be eaten again, an X-ray with contrast medium is taken.