The esophagus is a connecting tube between the pharynx and the stomach, which passes through a hole in the diaphragm. Disorders in the gastrointestinal tract provoke esophageal disease. These include gastroesophageal reflux disease, such as sliding axial hernia of the esophageal opening of the diaphragm (HHL).
During the development of the disease, the cardial section of the stomach moves to the region of the sternum through the diaphragmatic opening. There are several types of hiatal hernia:
- paraesophageal (this type is characterized by the fact that the increase and growth of the stomach occurs on the left side of the esophagus),
- axial (its main difference is the absence of a hernial sac, which allows it to penetrate into the chest cavity and freely return back). May have a fixed and non-fixed character,
- combined (with the development of both types of hernia - axial and paraesophageal).
Causes of axial hernia
Both congenital and acquired factors can affect hernia formation.
Damage to the phrenic nerve after inflammation or injury leads to relaxation of the diaphragm.
Congenital hernia of the esophageal orifice of the diaphragm, obtained as a result of delayed descent of the stomach into the abdominal section. This occurs during the development of the fetus in the womb.
Against the background of ulcers, holicistitis, gastritis, a reflex contraction of the esophagus walls occurs, which over time leads to an increase in the circumference of the diaphragm.
The diaphragmatic muscles are not fully developed, because of which the esophageal orifice ring in the diaphragm is expanded.
Pregnancy, constipation, lifting weights, smoking and other causes provoke an increase in intra-abdominal pressure and contribute to the formation of a hernia.
The late fusion of the diaphragm, after the stomach has descended into the abdominal cavity, leads to a pre-formed hernial sac.
Age involution of the muscle tissue of the diaphragm.
Symptoms and signs
At the beginning of the development of the disease, the symptoms almost do not appear, the clinical signs are mild and the hernia does not bother. It can be detected only by chance, for example, during a medical examination of an ultrasound scan. A visual inspection and palpation will not give results, since the hernia cannot be felt to the touch due to the deep location inside the thoracic region. It is difficult to recognize the axial hernia and the fact that it has the ability to periodically go back under the diaphragm.
The longer existence of a hernia or the slippage of a large part of the stomach into the region of the sternum provokes the onset of symptoms, therefore axial hernia is most often recognized already at later stages of development. Among the main signs accompanying the development of a hernia are the following:
- periodic heartburn (usually occurs after eating and lying down),
- burning and pain in the chest,
- exacerbation of bronchitis, tracheitis (pancreatic juice gets into the respiratory tract during belching),
- regurgitation (ingestion of food from the stomach into the esophagus and oral cavity without the gagging urge),
- dysphagia (a person cannot swallow as a result of cicatricial narrowing of the esophagus, which occurs due to the constant inflammation of his mucosa by acid emissions).
If the disease was not detected in time, then its further development can lead to serious complications. It may be ulcers and bleeding on their background. Periodic hemorrhages, in turn, can lead to anemia (anemia). At the slightest hint of a hernia, do not delay with the examination and subsequent treatment.
Diagnosis of a sliding hernia of the esophagus
Axial hernia can be diagnosed using X-ray, esophageal manometry, fibroesophagogastroduodenoscopy, gastroscopy, esophagoscopy.
- X-ray will determine:
- diaphragmatic opening diameter
- cardiac sphincter position
- the location of the lower esophagus,
- the location of the upper part of the stomach,
- delayed suspension of barium in the presence of a hernia.
Using fibroesophagogastroduodenoscopy determine the level of displacement of the esophageal-gastric line in relation to the diaphragm
- the level of displacement of the esophago-gastric line in relation to the diaphragm,
- the presence of ulcers, erosion, gastritis,
- inflammation of the mucous membranes of the stomach and esophagus.
In the early stages, surgery is rare. Most often, the doctor prescribes medication and diet, which involves the exclusion from the diet:
- fatty (meat - pork, cakes, cakes based on high-fat cream, etc.),
- hot (spicy seasonings, onions, garlic, black and red pepper),
- smoked (sausage, meat, fish, chicken products),
- fried (meat, potatoes, eggs, etc.),
- salted (cucumbers, tomatoes, sauerkraut, etc.),
- carbonated drinks (lemonade, mineral water),
- coffee, strong tea.
It is necessary to eat food in small portions (not more than 200 g at a time) 5-6 times a day. The stomach needs to be given time to process food and rest, so you should not do snacks, as they provoke the production of large amounts of gastric juice, which leads to heartburn.
You should not physically overstrain - it creates intra-abdominal pressure and provokes an increase in hernia. The number and intensity of the loads should be minimized.
In case of periodic heartburn, it is better to sleep lying on high pillows or to raise the head of the bed, if possible.
When diagnosing the disease in later stages, the hernia is removed with the help of a surgical procedure. The most common methods of getting rid of a sliding hernia are:
- Nissen fundoplication
- plastic topepe.
Laparascopy - the most common operation for today. Recovery after it is quick and painless.
The main aggravating symptom in the course of the disease is heartburn. You can eliminate it with the help of folk methods. Herbal teas or herbal teas are best for this:
- Tea from gentian helps not only to eliminate heartburn and inflammation of the esophagus, but also to establish digestion. A teaspoon of gentian is placed on one glass of water and infused over low heat for about 30 minutes. For taste, you can sprinkle with ginger and let stand for 10 minutes. It is not necessary to mix. The drug is taken before meals three times a day,
- Calendula and chamomile have anti-inflammatory effects. Tea from these herbs will relieve inflammation of the esophagus and soothe the stomach. On a glass of boiling water is placed in half a teaspoon of chamomile and calendula. It is necessary to insist at least 20 minutes. After receiving the infusion filtered and taken a glass 3-4 times a day. In the period of acute heartburn can be taken more often.
- decoction of herbs for heartburn. A tablespoon of the collection infused in 0.5 liters of boiling water for about 2-30 minutes. Strained infusion taken 15-20 minutes before meals. Must be mixed:
- young nettles,
- flaxseed soothes the stomach, reduces the acidity of its contents, relieves inflammation of the esophagus and heals the digestive system. A teaspoon of seeds is infused in a glass of hot water (no need to cook) for 30–40 minutes. You can wrap a towel to maintain the temperature. Infusion is filtered and taken shortly before meals. You can also add flaxseed oil in food, but not more than 3 spoons per day.
Diet after surgery
Compliance with the postoperative diet is necessary to reduce the degree of load on the gastrointestinal tract. To achieve this will help fractional nutrition and exclusion from it of products that provoke gas formation, contribute to constipation, etc.
After surgery, the doctor recommends that you stick to your diet and eat food, taking into account the individual characteristics of the patient.
What products can not be used after surgery?
From the diet should be excluded:
- flour pastry (cookies, cakes, cake, pancakes, pancakes, etc.),
- bran bread,
- fatty, smoked, salty, spicy, fried,
- legumes (peas, beans, etc.),
- tomatoes, cabbage, broccoli, carrots, garlic, onions,
- radish, turnip, radish,
- corn, millet, barley porridge,
- dairy products with a high percentage of fat,
- nuts, seeds, raisins, dried apricots, prunes,
- carbonated drinks, coffee, strong tea, juices with a high concentration of acid.
What products can be consumed after surgery?
After surgery, it is best to use:
- low-fat broths,
- vegetable soups,
- boiled lean meat or fish,
- cottage cheese (non-fat),
- liquid porridge,
- dried white bread in small quantities,
- Kissel (it is advisable to cook it not from dyes containing dyes, but from fresh berries).
The use of plant fiber can restore the gastrointestinal tract, but excessive consumption of vegetables can lead to stagnation of coarse fiber and the formation of feces in the intestine.
Products allowed for use in the postoperative period (gallery)
The best way to prevent hiatal hernia is to maintain a healthy lifestyle. The abuse of alcohol and cigarettes, unhealthy diet and lack of sports loads on the body leads to the development of multiple diseases of the digestive system, including axial hernia. At the first signs of the disease, you should consult a doctor and undergo a full examination of the abdominal cavity organs. Launched disease leads to more serious complications up to death.
How does the UK?
- on fixed,
- not fixed.
The first case involves a protruding stomach, the latter does not change its position from pressure surges, changing the posture of the patient.
The figure shows the penetration beyond the diaphragm of the stomach (FHPS)
In the picture, the hernia does not return to normal.
Locations not fixed hernia are changingBecause of this reason, it is sometimes called wandering. It is characterized by the fact that during a change in a person's posture to a horizontal one, the stomach returns. This form of the disease also needs treatment.
The disease is expressed by increased pain during a change in body position or physical activity. The appearance of internal bleeding is not excluded, the latter come out with emetic masses or stools. This happens more often when the esophagus is injured and ulcers form.
Recommendations to help hernia treatment without surgery
Most often, this pathology is treated without surgery, for this you need to change some habits, and then follow the recommendations of doctors.
- The first thing that gets eliminated is weight, which becomes a disease-provoking factor.
- Improper posture, lack of muscle tone of the diaphragm leads to deformation.
- In suspicion or when diagnosing a hernia, it is extremely important to avoid overvoltages, due to the lifting of heavy objects.
- Prolonged stay in an oblique pose can provoke a displacement of the stomach.
- In order to detect a hernia, it is necessary to conduct an examination of the gastrointestinal tract in the event of symptoms, treat gastritis, GERD (gastroesophageal reflux disease) in time if they show up.
- Medical gymnastics, proper nutrition reduce the risk of disease progression.
- Heartburn pains are reduced if you put a hard pillow under your chest at bedtime, at the same time reducing the size of portions of food.
- Swimming has a positive effect on the respiratory organs, which strengthen the muscles of the diaphragm and prevent the development of hernias. Therefore, it is recommended to visit the pool 4 times a week, taking into account the 30-minute session.
Compliance with simple recommendations accelerates the effectiveness during the struggle of the patient with the disease.
When surgery is required according to surgeons
Doctors came to the conclusion that surgery for hernia of the diaphragm is shown only in the most extreme cases when the results of other methods are powerless. The danger of operable intervention is provided by postoperative complications:
- seam divergence
- discomfort when swallowing
- the formation of relapses
- displacement of the compression grid,
- discomfort in the chest,
- lack of belching,
- damage to adjacent organs.
- a sharp decrease in pulse rate, pressure drop,
- damage to the teeth or vocal cords due to the tubes used,
- airway impairment,
On this video, from the popular program, the nutrition and treatment of hernia of the diaphragm is discussed.
Period after surgery
After the procedure, which lasts 2 hours, the person remains for some time under the supervision of doctors. In the absence of complications, the patient is discharged, sometimes in a day.
The parting words of the doctors during the recovery period are as follows:
- Physical loads are contraindicated for a person.
- The patient is important to comply with dietary rules of nutrition.
Operated people after 4 hours of operation, make light movements, without getting out of bed - turn over, lift, bend limbs. The second day provides for the intake of liquid food, followed by a strict diet of at least 60 days. Then, the diet is allowed to diversify, while you can not break the gentle mode for six months. Compliance with the recommendations will help the patient quickly return to the usual life, without dieting and medication.
Advantages and disadvantages of the operation on Nissen and Tupe
Nissen's and Tupe's operations are considered to be the claimed methods of hernia treatment. The basis includes the creation of a cuff around the lower esophagus using the fundus of the stomach.
The advantage of the latter type of plastic is a smaller number of complications, compared with the Nissen method, after which there may be:
- dysphagia (dysphagia),
- small ventricular syndrome,
- cascade stomach.
It is believed that the Nissen surgery, which cuffs envelop the stomach section around the esophagus by 360 ° is suitable for patients with normal or increased peristalsis of the esophagus. People with lethargic or weak peristalsis shows a Tupe fundoplication surrounding the organ 270 degrees.
The cost of surgical intervention for individual regions is different, for example, some clinics in the Sverdlovsk region suggest holding a fundoplication for 40 thousand rubles. Complications during operations often depend on the professionalism of the surgeon. For this reason, it is necessary to choose a surgeon and a clinic, having previously studied the experience of performing such procedures.
A hernia of the esophageal opening, with careful and careful handling of the regimen, diet, and load, does not require surgery. The restrictions that the HHC imposes on a person are aimed at improving well-being, getting rid of bad habits and giving joy from simple and, at times, undervalued things and the environment. Minimum monitoring of the body and care will return joy and everyday comfort.
Bottom line: the article examines the causes of the onset of the disease and provides recommendations to help treatment without surgery. The opinion of the surgeons on the reasons prompting to go for an operation is given. Examined by surgeons used methods. We hope this information will be enough for you to avoid surgery, or, in cramped circumstances, choose the most benign.
Causes of the disease
Formed sliding hernia of the esophagus under the action of congenital and acquired factors. The first is the abnormally shortened esophagus, when a certain part of the stomach is located in the sternum.
The acquired causes of a sliding hernia are:
- liver atrophy,
- multiple pregnancy,
- weakening of the food sphincter (age)
- chronic constipation
- lifting excessive severity
- esophageal dysfunction
- pathology of the gallbladder,
- esophageal mucous burn with chemicals or hot food
Symptoms and diagnosis of pathology
The disease can be completely hidden. Indirect symptoms include:
- pain in the sternum,
- asthma attacks
- prolonged cough,
- prolonged heartburn.
The presence of problems with sliding axial hernia is signaled by an unpleasant exhaled odor, frequent exacerbation of tracheitis, when pancreatic juice penetrates with belching into the respiratory tract.
Sliding hernia of the esophageal opening of the diaphragm (HH) is diagnosed by laboratory and instrumental methods:
- a fecal occult blood test,
- X-ray of the esophagus, stomach and chest organs,
- endoscopic biopsy,
- biopsy study.
Treatment of glutous HHV is usually conservative. At the initial stage, surgery is rarely used. The disease is classified by 3 degrees. At the first - the diet is appointed, excluding:
- fat (pork, cakes),
- smoked (fish, sausage),
- fried (potatoes, meat),
- spicy (seasoning, onion and garlic),
- salted (cabbage, cucumbers).
Treatment involves eating small amounts of food up to 6 times a day. For 1 reception more than 200 grams can not be consumed. A stomach that has processed food requires rest, so snacking should be avoided. They contribute to the production of excess volume of gastric juice, it provokes heartburn.
Physical overstrain is also dangerous, intra-abdominal pressure increases, leading to an increase in hernia. With heartburn it is recommended to sleep, raising the head.
Specialists consider risk factors as:
- weakness of the ligaments that strengthen the esophagus,
- abdominal pressure jumps,
- displacement of the esophagus with impaired motility of the digestive system.
Drug treatment eliminates the main symptoms, but requires an integrated approach to prevent complications. Usually experts prescribe:
- Almagel, Rennie, Maalox - antacid agents that have a binding effect on hydrochloric acid, which is in the gastric juice and prevents irritation of the esophagus.
- Inhibitors. Omeprazole, Esomeprazole, Pantoprazole reduce the amount of acid production.
- Prokinetics. Cisapride, Metoclopramide, Domperidone prevent penetration of stomach contents into the esophagus.
- Histamine receptor blockers. Ranitidine, Famotidine, Roxatidine reduce the secretion of hydrochloric acid and its flow into the stomach.
Surgical treatment is carried out in the following cases:
- with the ineffectiveness of conservative therapy,
- with enlarged hernia,
- with dysplasia of the mucous membrane of the esophagus,
- in the presence of complications HH,
- with a high risk of infringement of the obesophageal hernia.
Axial hernia of the esophageal opening of the diaphragm with the help of surgery is treated by the following methods:
- Nissen fundoplication
- plastic topepe.
Laparoscopy is the most popular surgery. Punctures are made in the area of hernia development. The surgeon observes the course of the procedure through a video monitor. The recovery period after the intervention is short and painless due to the lack of large incisions.
Fundoplication according to Nissen is performed openly or using laparoscopic equipment. The goal is to stop the development of reflux (abnormal movement of the contents of hollow organs). Hernia growth also ends.
Toupe surgery is an open type of surgery. The esophagus is cut longitudinally and insert part of the diaphragm. Splicing occurs quickly, because the tissues of these organs are identical.
For the 1 st degree of the disease, only the lower part of the esophagus penetrates into the sternum, so surgical treatment is not indicated.
After completion of the operation requires a diet to reduce the load on the gastrointestinal tract. The patient should stop using foods that cause constipation and gas formation. Excluded from the diet:
- fried, smoked, fat,
- nuts, eggs, prunes.
Treatment of sliding hernia with recipes of traditional healers is not capable of giving the desired result. In many cases, medication or surgery is required. Decoctions and infusions of herbs can not be removed hernia, but you can ease the pain.
HH affects up to 6% of the adult population. If you start the disease, it will lead to the development of dangerous complications (ulcers, bleeding). Periodic hemorrhage can cause anemia (anemia). Treat the disease should only a specialist.
Sliding hiatal hernia
Photo: sliding hernia
A sliding hernia of the esophageal opening of the diaphragm (hiatal hernia, sliding hiatal hernia) or a hernia of the esophagus is the movement of the stomach or other abdominal organs through the expanded esophageal opening in the diaphragm into the chest cavity.
There is a disease in 5% of the total adult population, despite the fact that half of the patients do not mark any clinical manifestations.. This is so because with a sliding hernia of the esophageal orifice of the diaphragm, the symptoms (signs) of a typical hernia are erased, as it is inside the body and cannot be seen during a routine examination of the patient. It is more often observed in women than in men, in children they are mostly inborn.
Sliding (axial) hernia of the esophageal opening of the diaphragm (HHL), relating to one of the variants of hernias of the esophageal-gastric orifice in the diaphragm, is subdivided into:
- total gastric,
- subtotal gastric.
Another hernia variant is paraesophageal, classified into:
- stuffing box
There is also a classification depending on the volume of the stomach penetrating into the chest cavity:
- a sliding hernia of the esophageal orifice of the 1st degree diaphragm - above the diaphragm, in the cavity of the thorax the abdominal part of the esophagus is located, at the diaphragm level the cardia is located, the stomach is in an elevated position and is adjacent to the diaphragm,
- the sliding hernia of the esophageal opening of the diaphragm of the 2nd degree - the abdominal part of the esophagus is located in the chest cavity, and the part of the stomach is located directly in the area of AML
- sliding grade 3 hernia of the esophageal orifice of the diaphragm - the abdominal part of the esophagus, the bottom and the body of the stomach (sometimes the antrum), the cardia are located above the diaphragm.
Symptoms of a sliding hernia of the esophageal opening of the diaphragm (stomach)
Symptoms are more likely to be associated with diseases of the gastrointestinal tract, due to the disruption of its functioning. With the deterioration of the activity of the lower esophageal sphincter, gastro-esophageal catarrhal reflux is observed (injection of gastric contents into the esophagus). After a certain period of time, inflammatory changes appear in the lower part of the esophagus due to the aggressive contents of the stomach.
The patient has the following complaints: heartburn after eating, aggravated during exercise, in a horizontal position. Frequent complaints about the feeling of a lump in the throat.
There may be pain immediately after a meal, having a different character, giving up to the sternum, neck, scapula, lower jaw, in the region of the heart. Such pains resemble angina with which the differential diagnosis. Sometimes pain when sliding HH occurs only at a certain position of the body. Possible patient complaints about abdominal distention in the upper part, foreign body sensation.
In more severe cases, as a complication, there is bleeding from the vessels of the esophagus, which, most often, is hidden and manifests itself only with progressive anemia. Hemorrhages are acute and chronic, there are even pinching of the hernia in the esophageal opening of the diaphragm and esophageal perforation.
Reflux esophagitis is the most common consequence of a hernia of the AML, which can transform into a peptic ulcer of the esophagus.
In the long run, this condition leads to a more severe complication - cicatricial stenosis (narrowing) of the esophagus.
For the diagnosis using esophagogastroduodenoscopy, X-ray examination of the stomach and esophagus, ultrasound, intra-esophageal PH-metry, esophagometry, computed tomography.
Treatment of sliding hernia of the esophageal orifice of the diaphragm (stomach)
In cases of sliding hernia of the stomach, a conservative treatment is first recommended, it is aimed more at relieving the symptoms of reflux esophagitis: heartburn, nausea, pain. Drugs that reduce the acidity (PH) of gastric juice are used (such as the drug Quamatel from Gedeon Richter).
The patient must follow a diet with the restriction of spicy, fatty, fried foods, chocolate, coffee, alcohol, all products that contribute to the development of gastric juice. There is a need often, in small portions. To avoid reflux, it is recommended to sleep with a raised upper part of the body, avoid lifting weights.
But, unfortunately, the conservative therapy of the sliding hernia of the esophageal orifice of the diaphragm, the treatment of which was carried out with medication, diet, does not eliminate the cause of the disease (the hernia itself) and brings only a temporary effect. Therefore, a planned operation is recommended.
For surgical treatment of HH, the criteria are:
- the presence of complications such as bleeding, anemia, ulcers and erosion of the esophagus, esophagitis,
- the inefficiency of conservative treatment methods,
- large sizes of sliding gastric hernia and its fixation in the hernial ring,
- perioesophageal (paraesophageal) sliding hernia, due to the high risk of infringement,
- signs of dysplasia of the esophageal mucosa, which acquires signs of the structure of the mucous membrane of the small intestine.
The essence of the operation is to restore the correct anatomical relationship between the stomach and the esophagus: elimination of the hernia, elimination of the hernia gate by suturing the esophageal opening of the diaphragm to normal size and creating an antireflux mechanism that prevents the gastric contents from being thrown into the esophagus.
Today, there are two types of techniques used for surgical treatment.:
- open access - Nissen fundoplication (complications of which may be early dysphagia, small ventricle syndrome, cascade stomach) or, more preferably, Tope plastic (with fewer complications),
- laparoscopic access - allows you to perform the operation less traumatic (with the size of incisions 1-2 mm by 5-10 mm), contributes to a more rapid recovery of the patient after surgery.
Laparoscopic surgery for hernia of the esophageal orifice of the diaphragm is often combined with surgery of other abdominal abnormalities: cholecystectomy is performed in chronic calculous cholecystitis, and in proximal duodenal ulcer, selective proximal vagotomy.
Hernia of the esophagus most often occurs in adulthood.
Depending on the location of the defect are distinguished:
- axial hernia,
- cardiac arrest.
There are several types of pathology:
- shortened esophagus (detected in people with a congenital defect),
- paraesophageal hernia,
- sliding hernia.
A feature of the sliding hernia is the difficulty of diagnosis. The reason is that the symptoms of this disease are quite weak. Self dumping can only be determined under certain conditions.
A distinctive feature of this defect is that the displacement in the sternum occurs along the axis of the esophagus. The location of the hernia affects the position of the upper part of the stomach. In this case, the ejection leads to the fact that the upper part of the patient's stomach is above the level of the diaphragm.
The stomach is involved in the formation of hernia formation. There are 2 types of sliding hernia: fixed and non-fixed. The position of the patient does not affect the location of the hernial bag. If a person assumes an upright position, then a fixed hernia will remain in the sternum. Formation keeps adhesions that form in the area of the hernia.
Experts distinguish sliding hernias with congenital and acquired defects. There is a difference in pressure between the sternum and the abdominal cavity. Thanks to this differential, the contents of the stomach enter the esophagus.
The mucosa of the esophagus is sensitive enough to similar substances. This causes erosion and ulceration. The patient experiences discomfort, discomfort and severe pain. The inflammatory process in the esophagus develops gradually. At the same time the mucous membrane bleeds and is permanently injured.
The patient begins to have anemia associated with iron deficiency due to the development of tissue.
What is a hernia of the esophageal opening, tell the video:
The causes of the formation of a sliding hernia
Increased salivation is a sign of a sliding hernia.
The condition of the ligaments affects the formation of the esophageal opening of the diaphragm.
The upper part of the stomach in this disease is shifted upwards. This leads to the fact that the muscular ligament becomes much thinner.
Stretching the ligament provokes an increase in the diameter of the esophageal opening. The patient develops a complication with regular overeating. In case of detection of such a defect, the doctors refer the patient to the operation.
There are several methods for removing hernia. Thanks to the fundoplication around the esophagus, the surgeon creates a special cuff. It prevents the stomach contents from being thrown into the esophagus. During the operation, the laparoscopic method is used. With it, doctors can reduce trauma to a minimum.This shortens the length of the patient's recovery period.
However, we can not exclude the possibility of sliding cuff. This increases the risk of complications after surgery. Surgical intervention in most cases helps to achieve positive results. Success is largely dependent on the passage of physiotherapy during rehabilitation.
Sometimes hernial vyvalivaniya is fixed in one position. This is due to the narrowing of the scars in the hernial sac. At the same time, the acquired shortening of the esophagus is revealed in the patient. Gastrointestinal canal is located above the diaphragm.
In severe cases, a person may experience fibrous stenosis. A complication of a sliding hernia is also reflux esophagitis. Sliding dumping cannot be affected. If there is a narrowing of the hole, then the cardia is squeezed, which enters the sternum. This condition does not lead to impaired circulation.
What are the signs of the disease?
Heartburn is a symptom of a sliding hernia.
Sliding hernia of the esophagus has no vivid manifestations. Symptoms in a patient manifest themselves only in the event of various complications of the disease.
There are several characteristic signs of a sliding hernia of the esophagus:
- the patient starts to complain of heartburn,
- he suffers from belching attacks,
- there is pain in the esophagus,
- there is regurgitation after eating,
- people experience a burning sensation behind the sternum,
- a lump appears in the throat,
- there is increased saliva production,
- blood pressure rises in some patients.
Symptoms of the disease depend on the position of the patient. Burning occurs in almost every person with this pathology. Severe pain is experienced by a person with a stomach ulcer. A large amount of food can cause pain in the esophagus.
By taking acidic lowering agents, you can get rid of discomfort.
How is the diagnosis
To identify a rolling education, experts use several methods:
- In the process of gastroscopy, doctors use endoscopic equipment to determine the inflamed areas, the presence of ulcers and erosions,
- roentgenoscopy of the stomach is intended to assess the condition of the hernias,
- The study of changes in daily pH in the esophagus is designed to determine the increased acidity, which leads to the appearance of painful sensations.
Features of treatment
Maalox will help reduce the acidity of the esophagus.
To eliminate the defect, doctors use traditional methods. The complex of therapeutic measures includes a special diet, physiotherapy, medication.
To reduce the acidity, doctors prescribe antacids to patients (Phosphalugel, Maalox). To help patients suffering from bouts of belching, you can use Motiliuma. The dosage is indicated by the doctor according to the patient’s condition.
However, with serious complications, these methods do not allow to achieve positive results. In this case, the patient is sent for surgery.
Sometimes in patients with cuff slippage occurs, and the disease occurs again. To help such patients can re-operation.
Patients need to follow a diet. At the time of illness will have to abandon the use of fatty and spicy foods. Eliminate smoked meats and marinades. Eating should be taken in small portions to speed up the digestion process.
After surgery, patients can not engage in intense physical labor. It is forbidden to do exercises that provoke an increase in pressure in the abdominal cavity.
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Prerequisites for the formation of a hernia
Sliding or axial hernia is formed after the displacement of the part of the stomach and the lower esophagus from the abdominal cavity to the chest. This type differs from the usual hernia in that it does not have a hernial sac. This disease is critical to the usual human activity is not affected. Long asymptomatic, unhurried progress often does not let the patient know about his illness for a long time. Sometimes signs of a sliding hernia of the esophageal opening of the diaphragm become visible when visually examining the abdominal cavity for a completely different reason.
Congenital and acquired factors can provoke loss. Congenital causes include the following phenomena:
- the diaphragm overgrown at the wrong time
- in the embryo, the stomach went down not fast enough
- the muscles of the legs of the diaphragm have not fully developed,
- the opening of the esophagus is enlarged.
Acquired causes of the formation of a floating hernia of the esophagus:
- high intra-abdominal pressure
- relaxation of the diaphragm, trauma or inflammation of its nerve,
- age changes of the diaphragm,
- cholecystitis, ulcers and other enhanced contractions of the esophagus.
In addition, axial hernia can be obtained after pregnancy, as a consequence of childbirth, due to obesity, and it also appears along with certain stomach diseases that increase intra-abdominal pressure. A wide range of provoking factors means that this ailment is widespread and can affect almost anyone. But having studied the symptoms and treatment, it is necessary to arm yourself and prevent the formation and progression of a hernia.
Symptoms of the disease
It is not always possible to understand what a sliding hernia is. Moreover, focusing on its symptoms, because they are just as common and familiar to a person as, say, a headache. So, the characteristic signs of this disease are heartburn and stomach pain. With a small amount of gastric protrusion, the symptoms are mild, an external examination by a doctor does not give any results, since external factors indicating problems are mild. However, the long course of the disease without proper intervention results in the discharge of the contents of the stomach into the esophagus, resulting in irritation of the mucosa.
Sliding hiatal hernia is characterized by the following symptoms:
- Severe heartburn when lying down after eating,
- Belching, accompanied by the release of food through the esophagus into the oral cavity, and the gag reflex is absent.
- Burning and pain in the chest and epigastric region, especially pronounced symptoms become when bending.
- Violation of the process of swallowing. Reflex impairment (swallowing the fluid is not accompanied by characteristic sensations) is gradually replaced by inflammation of the mucous membrane when the esophagus narrows and the lump of food hardly goes down.
- Regular tracheitis, bronchitis, less inflammation of the lungs, and all because during eructation in the airways penetrate acid from the stomach.
Sometimes the patient has increased blood pressure and increased salivation. The painful sensations accompanying a sliding hernia are unlike the pains of a stomach ulcer.
Fibrogastroduodenoscopy and ultrasound are ineffective in identifying the sliding HH. An X-ray machine can accurately diagnose a hernia. In some cases, the symptoms of the disease occur with magnetic resonance imaging. Other methods of examination can provide an accurate diagnosis and prescription of effective treatment:
- Endoscopy, preferably combined with x-rays.
- PH-metry of the esophagus.
- Gastroscopy, sensing of the affected area.
- Study of the functioning of the esophageal-gastric junction.
The established diagnosis should be promptly analyzed by a specialist who will prescribe an emergency treatment of sliding hiatal hernia and possible surgical intervention.
Treatment of sliding hiatal hernia
Despite the possible late detection of a sliding HH, it can be cured by conservative methods. Doctors use the surgical approach for bleeding in the esophagus, as well as in the later stages of the disease.
A conservative method for the treatment of esophageal sliding hernia requires an integrated approach, so the following instructions must be followed without fail:
- Dieting is a must. It is necessary to exclude from the diet fatty foods, spicy dishes, marinades, smoked and all fried. So it is possible to avoid abundant secretion of gastric juice and irritation of the mucous. Menus should be steamed, stewed and boiled. From products, cereals, fruits, vegetables, dietary meat and milk are preferable. Constant adherence to the diet, refusal to eat before bedtime and a ban on lying rest after a meal is the first step to an absolute cure.
- Bringing the rhythm of life back to normal - for starters, you should give up bad habits such as alcohol and smoking. It is necessary to do physical exercise more moderately, to provide a complete rest at night and short breaks from work during the day. Strongly contraindicated exercises that increase the load on the abdominal cavity.
- Drug treatment - the appointment of the attending physician necessary for this diagnosis of drugs. Gastal and Maalox (they lower the acid content in the stomach), Omez (suppresses the production of hydrochloric acid), Motilium (struggling with belching and heartburn), antispasmodics and drugs for epigastric pain, such as No-spa.
Sliding hernia of the esophagus is not the most difficult disease, but if the patient still has not coped with its elimination on its own, it is necessary to resort to surgery, which happens very rarely.
Symptoms of sliding hiatal hernia
Sliding hernias, according to the classification of B. V. Petrovsky and N. N. Kanshin, are divided into:
and giant (subtotal and total gastric), in which the stomach moves into the chest cavity.
Sliding hernia can be fixed and non-fixed. In addition, an acquired short esophagus, in which the cardia is located above the diaphragm, and the congenital short esophagus (chest stomach) are isolated.
Types of sliding hernias and their signs
Sliding hernias can be:
Symptoms of sliding hernia of the esophageal orifice are due to reflux esophagitis. Patients complain of burning or dull pains behind the sternum, at the level of the xiphoid process, in the epigastric region, in the hypochondria, radiating to the heart region, scapula, left shoulder (often patients are seen by the therapist for angina).
The pain increases in the horizontal position of the patient and during physical exertion, when the body bends forward, that is, when the gastroesophageal reflux occurs more easily. The pain of the hiatus hernia is accompanied by belching, regurgitation, heartburn.
Over time, patients have another hernia symptom - dysphagia, which is often intermittent in nature and becomes constant with the development of peptic stricture of the esophagus.
A frequent symptom of the disease is bleeding, which is usually hidden. It is rarely manifested by vomiting with blood of scarlet or the color of coffee grounds, tarry stools.
Anemia can sometimes be the only symptom of a hernia. Bleeding occurs by diapedesis, from erosions and ulcers in peptic esophagitis.
Symptoms of paraesophageal hernia of the esophagus
Paraesophageal hernia is divided into
- and antral,
- as well as mixed types of hernia.
Symptoms of paraesophageal hernia fundal type
Most often there is a shift of the abdominal esophagus up into the chest cavity. In this connection, this part of the esophagus expands above the diaphragm, loses its tubular appearance, becomes similar to a hernia of the esophageal opening of the diaphragm. These are hernias of type I, they make up about 90% of all hernias. Such hernias are usually asymptomatic. The onset of symptoms is usually associated with reflux esophagitis.
Manifestations of antral hernia
With a hernia of this type, the cardia and the ventricular diaphragmatic ligament remain in place, and the peritoneal hernia sac moves into the mediastinum along the esophagus through an opening in the diaphragm. Fundus, and sometimes the entire stomach move through this defect in the mediastinum and are located in the paraesophageal tissue. In this case, the gatekeeper rises to the level of the cardia. Antral hiatal hernia is rare (about 2%). Hernias of this type may be asymptomatic for some time. If symptoms occur, such a hernia should be urgently operated to prevent pinching, necrosis of the stomach wall and perforation. When such a hernia is an accidental find, then in the elderly and in patients with severe concomitant diseases that are of great risk, you can not be in a hurry with surgery.
Manifestations of hernia of mixed type
In type III hernia, a combination of a sliding hernia with a type I — II hernia is observed. In this case, cardia is located in the chest cavity. Type III hernia is sometimes observed in obesity and is subject to prompt repositioning.
In type IV hernia, there is a massive (large) hernia, in which intestines and other organs can move along with the stomach into the chest cavity. Patients usually have reflux esophagitis.
Diagnosis of hernia hiatus
Radiological and endoscopic examination is crucial in establishing the diagnosis. The study is carried out in the vertical and horizontal positions of the patient and in the Trendelenburg position (with the head end of the table lowered).
With sliding hernias, a continuation of the folds of the mucous membrane of the cardial section of the stomach above the diaphragm, the presence or absence of shortening of the esophagus, an unfolded angle of the gis, a high confluence of the esophagus into the stomach, a decrease in the gas bubble, a reflux of the contrast substance from the stomach into the esophagus are noted.
The location of the cardia over the diaphragm is a pathognomonic symptom of cardiac hiatal hernia. With concomitant reflux esophagitis, the esophagus can be enlarged and shortened.
More accurate information about the state of the mucous membrane with a hernia gives esophagoscopy. It allows you to identify the peptic stricture of the esophagus, ulcers, cancer, bleeding, specify the length of the esophagus, assess the severity of esophagitis, determine the degree of insufficiency of the lower esophageal sphincter, eliminate the malignancy of ulcers. The presence of gastroesophageal reflux can be confirmed by intra-esophageal pHmetry (decrease in pH to 4.0 and below).
In paraesophageal hernias, the symptoms depend on the type of hernia, the contents of the hernial sac, the degree of mixing and bending of the organs in the hernial sac and their dysfunction. Symptoms of disorders of the digestive tract, cardiovascular or respiratory systems may prevail. During roentgenoscopy of the chest in the posterior mediastinum on the background of the shadow of the heart reveal a rounded enlightenment, sometimes with a fluid level. When contrasting the stomach, they clarify the location of the organ that fell out and its relationship with the esophagus and cardia. Esophagogastroscopy is indicated when an ulcer, polyp, or stomach cancer is suspected.
Surgical removal of a food hole hernia
For uncomplicated sliding hernias, conservative treatment is performed, which is aimed at reducing gastroesophageal reflux. Surgical treatment of hernia of the esophageal orifice of the diaphragm is indicated for bleeding, the development of peptic stricture of the esophagus, as well as the failure of long-term conservative therapy in patients with severe symptoms of reflux esophagitis
In case of paraesophageal hernias of the II, III and IV types, surgical treatment is indicated in connection with the possibility of infringement of the hernial contents.The operation consists in bringing the organs into the abdominal cavity and stitching the edges of the esophageal opening of the diaphragm behind the esophagus. When combined paraesophageal hernia with insufficiency of the lower esophageal sphincter, the operation is complemented by Nissen fundoplication. When strangulated hernia patients operate in the same way as with other diaphragmatic hernia.
Indications for esophageal hernia surgery
Most authors agree that surgical treatment should be resorted to only under strict indications. Among them, we will call reflux esophagitis (ER), severe, rezenstentny to medicinal effects or accompanied by stenosis of the esophagus.
Gigantic hernias that cause compression of adjacent organs, hernias complicated by persistent anemia or repeated massive bleeding are also subject to surgery.
The prudent approach to surgical treatment is dictated by the characteristics of the contingent of sufferers. Among them are dominated by persons of older age groups, often burdened with concomitant diseases:
- arterial hypertension,
- coronary heart disease,
- diabetes mellitus.
This significantly increases the risk of surgical treatment of hernia, which, moreover, does not always provide lasting positive results. Here the commonality of constitutional and pathogenetic prerequisites of the listed diseases and the HHL is reflected. The development of the latter is promoted by chronic entero- and colonopathies leading to an increase in intraperitoneal pressure. Hence the frequent joining of a hernia to a long-term irritable bowel syndrome, constipation.
The above makes it possible to understand why when choosing dietary and drug prescriptions for treating a hernia, one has to proceed not only from the peculiarities of the clinical manifestations of the hernia of the esophageal opening, but also from the nature of the diseases associated with it. It would, of course, be unrealistic to try to envisage all possible combinations here. Hence the need for an individual approach with the introduction of appropriate adjustments to the treatment tactics set out below.
Conservative treatment of hernia of the esophagus
Speaking about the conservative treatment of hernia, we immediately select the obvious fact that it is not able to eliminate the anatomical defect that constitutes its essence. It would, however, be hastily concluded that this predicted the ineffectiveness of drug therapy. On the contrary, in most cases, the conservative treatment of a hernia of the food hole provides a varying degree of success and should be regarded as the main one.
Objectives of conservative therapy of the hernial esophageal opening
Based on the pathogenetic mechanisms and clinical symptoms of hernia, we can formulate the following main tasks of its conservative treatment:
reduction of aggressive properties of gastric juice and, above all, the content of r iici hydrochloric acid:
prevention and restriction of gastroesophageal reflux,
local medicinal effect on the inflamed esophageal mucosa of the hernial part of the stomach
reduction or elimination of esophageal and gastric dyskinesia
prevention and restriction of trauma in the hernial ring of the abdominal segment of the esophagus and the prolapse of the stomach.
Cholinolytic drugs in the treatment of esophageal hernia
The choice of their specific representatives and combinations with each other and other means depends on a number of factors. Among them, first of all, we call the consideration of the severity of the antispasmodic activity of individual drugs. From the number anticholinergic agents when taken orally derivatives of bellow, first of all Atropine, clearly superior in this regard Platifillin and especially Metacin. The latter, due to its low bioavailability when administered orally in an officinal dosage, reveals only a very moderate antispasmodic ability.
At the same time, a large anticholinergic activity of belladonna derivatives is a source of frequent side effects. This is especially true for Atropine and, to a lesser extent, to the newer, more powerful non-selective anticholinergic, chlorosyl, administered 2–4 mg 3 times a day orally.
Most of the contingent of patients are representatives of the older age groups, and mostly women. It is this contingent of people that is sensitive to Atropine, which, even in small doses, is sometimes poorly tolerated. It should be noted that, like all other non-selective anticholinergics, Atropine is contraindicated for treatment with glaucoma and prostate adenoma, which are not uncommon in the elderly. We will immediately stipulate that the foregoing does not at all serve as a call for the rejection of the use of Atropine and other anticholinergic agents for hernia of the esophageal opening (but without reflux esophagitis!). It is only a matter of reasonable discretion.
Noting some of the negative aspects of anticholinergic agents, it would be unforgivable to pass by their therapeutic merit. The main of them is a pronounced antispasmodic effect, significantly exceeding that of drugs with myotropic activity. Parenteral administration of Atropine, Metacin, Platyfillin manages to stop the most intense pains of spastic genesis, which myotropic drugs are usually not achieved.
From the above it follows that the appointment of anticholinergic drugs for hernia of the esophageal opening is advisable in cases with moderate, and even more intense, pain of a spastic nature or suspicion of one.
Myotropic antispasmodics in the treatment of hernia of the esophagus
However, myotropic antispasmodics find at hernia of an esophageal opening the scope of application. Their main representatives No-spa, papaverine, but with some reservations and Halidor> have a mild antispasmodic effect combined with good tolerance. From here it is appropriate to use them in cases with slightly pronounced pains, in addition to anticholinergic agents for enhancing their action, and also as a means of follow-up during a diminishing exacerbation.
With an average intensity of pain treatment, it is advisable to start with the appointment of drugs containing belladonna extract. Of these, there is reason to prefer Bellastezinu. Older women are initially prescribed "/ z, and the rest of the patients take 1 tablet 3 times a day 20-30 minutes before a meal. With good tolerance, but insufficient effect, the dose, respectively, can be increased to 1 and 1.5-2 tablets per reception, focusing on the appearance of mild dryness in the mouth.
To enhance the antispasmodic action in the treatment of hernia of the esophageal opening, immediately or several days later, No-silo or Papaverine, 0.08– 0.12 g (2-3 tablets), 3 times a day, are added to Bellastezin. The highest of these doses should not cause concern in relation to tolerability, and caution is needed only when arterial hypotension and prostate adenoma II-III degree.
In addition, as a spasmolytic can be used Tslatifillip (in the average dose of 0.005 g per reception).
It is less advisable to resort to Baralginu, Spazmalgonu, Bellalginu, since Analgin, contained in these preparations, is capable of irritating the gastric mucosa, which, especially in its prolapse part, often occurs when the esophageal hernia is damaged. In addition, prolonged use of drugs containing Analgin can be complicated by granulocytopenia and even agranulocytosis.
Treatment of acute pains with esophageal hernia
A different therapeutic approach is required by the attacks of acute pain that occur in patients. Of all the mentioned antispasmodic agents, only one when ingested is capable of responding to the task of stopping them. We are talking about Atropine, which is quickly and almost completely absorbed, and therefore, when taken orally, it gives little effect from that achieved by parenteral administration. Only the dose of Atropine should be adequate to those usually used when injecting it — 20-24 drops of a 0.1% solution.
Simultaneously with Atropine, it is advisable to take 3 tablets of No-shpy with acute pain. Thus, the pain is usually eliminated in 30-45 minutes, which makes an emergency call unnecessary.
With such treatment, only occasionally it is necessary to resort to parenteral administration of Atropine, Platyphyllinum, and preferably Metatin, alone or in combination with Papaverine, No-shpa, Analgin, Dimedrol. A good analgesic effect is also achieved by intramuscular injection of Baralgin.
The analgesic effect of anticholinergics and myotropic antispasmodics increases with their joint appointment with psychotropic agents. This clearly appears in cases of a combination of hernia of the esophageal orifice with neurosis, which is by no means uncommon. Hence we can conclude that the main importance in the treatment of pain in hernias here is not an increase in the antispasmodic effect, but an increase in the threshold of pain sensitivity under the influence of psychotropic drugs. Of these, benzodiazepine derivatives (Mezapam, Nozepam, Chlozepid, Sibazone) are more often resorted to, but depending on the nature of the neurosis also moderate doses of neuroleptics and antidepressants. The latter, however, is not recommended to be combined with metoclopramide.
Treatment of complications of hernia hiatus
Clinically the most significant symptoms of a hernia are due to gastroesophageal reflux. Its occurrence is triggered by an increase in intra-abdominal pressure, as well as body positions, facilitating the entry of stomach contents into the esophagus.
Until recently, in the literature there was no general point of view on the approach to the medical treatment of hernia of the esophageal orifice of the diaphragm and, above all, of the associated reflux esophagitis. [Vasilenko V. X., Grebenev A. L., 1978]. However, over the past decade since, the situation has changed significantly.
This is due to the emergence of a number of new effective drugs for the treatment of hernia. True, disagreements persist over a number of aspects of pharmacotherapy, but over the main points considerable unanimity is achieved. In this regard, we emphasize the need to distinguish between the manifestations of a hernia of the esophageal orifice caused by esophagitis from symptoms not related to it. It is this differentiation that constitutes an important condition for choosing rational pharmacological interventions.
Obviously, with such different prerequisites for the development of reflux esophagitis, a monotonous approach to the treatment of hernia is hardly justified. And yet, there are two main therapeutic goals that define, if not identity, then the general direction of pharmacological effects. The first is the restriction of gastroesophageal reflux, the second is the reduction of the pathogenic effect of gastric or duodenal contents regurgitating into the esophagus.
Both of these treatment goals, depending on the specific pathological situation, can be realized with the help of various pharmacological agents.
In this variant of the hernia in the center of the clinical picture are pain. The mechanism of their occurrence is heterogeneous, but esophagism is considered to be the main one. It can be triggered by traumatization of the esophagus and stomach in the area of the hernial ring, which, by the way, is in itself capable of causing pain. Another source is gastritis and erosion of the mucous membrane of the prolapse part of the stomach. The pain arising on the background of hernia of the esophageal orifice can have both spastic and distention genesis.
Variable and the intensity of pain with a hernia. It ranges from a feeling of heaviness in the epigastric region to one that induces an emergency call. The latter, however, occurs infrequently.
Evaluation of the genesis of pain is not an easy task, but we must strive to solve it. In addition to the signs that distinguish the spastic nature of pain from those of other origin, it is often necessary to focus on the effect of drugs, primarily antispasmodics.