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

Pathologies associated with disruption of the gastrointestinal tract are always a big trouble for a person. Interfere with one of its basic physiological needs - nutrition. Esophagus - an integral link in the system of delivering food inside the stomach, where it begins to digest. It is a fairly narrow tube of muscles, the length of which in an adult is a quarter of a meter. Getting from the mouth into the esophagus, the food is saturated with mucus and with the help of their reduction - peristalsis moves to the stomach. It ends with a sphincter - a special closing system that does not allow content to be sent back. Despite the simplicity of the anatomy of the organ, there are many of its pathologies, including hernia of the esophageal aperture of the diaphragm.

[1], [2], [3], [4]

Epidemiology

According to statistics, in the study of hernia of the esophagus is found in 5-7% of patients who have treated with complaints of stomach problems. From all types of hernia these make up 2%. It affects more women than men and older people.

[5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19]

Causes of the hernia of esophagus

The main tendency of the appearance of hernias is an imbalance between intra-abdominal pressure and resistance to the abdominal muscles. Why is this happening? The reasons leading to this can be covered in:

• features of the constitution of a person passed to him by inheritance;
• age changes accompanied by thinning of connective tissues;
• pregnancy, severe labor;
• physical labor, requiring high voltage;
• weight changes: obesity or exhaustion;
• chronic pathologies of the digestive system associated with impaired motor activity of the stomach, gallbladder, duodenum;
• individual diseases of endocrine glands.

[20], [21], [22]

Risk factors

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

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

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

[23], [24], [25], [26]

Pathogenesis

What is the hernia of the esophageal aperture of the diaphragm, its other name is hiatal? The diaphragm is the basic muscle that separates the space from the abdominal organs from the thoracic organs. It has a domed shape, directed upwards, with a hole for the esophagus in the center. The pathogenesis of the disease consists in the displacement of one or another organ of the abdominal cavity to the thoracic through this opening due to the weakening of the diaphragm, as well as its other defect. This occurs when inhaling, when the opening expands and the so-called hernial gates are formed. At this time, the peritoneal organs get free access to the thorax and move there.

[27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38], [39], [40]

Symptoms of the hernia of esophagus

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

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

Hernia of the esophagus in the child

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

[41]

Herniated hernia in pregnancy

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

Stages

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

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

[42], [43], [44], [45], [46], [47]

Forms

Hernias of the esophagus are classified as follows:

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

[48], [49]

Complications and consequences

Hernia of the esophagus can lead to such serious diseases as:

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

Can the hernia of the esophagus disappear? By itself, it does not go anywhere, but if you follow the rules of nutrition, a healthy lifestyle, strengthening the walls of the abdomen with it you can live if it is in the first two stages of development.

[50], [51], [52], [53], [54], [55]

Diagnostics of the hernia of esophagus

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

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

In case of bleeding, the level of erythrocytes decreases.

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

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

[56], [57], [58], [59], [60]

Differential diagnosis

The multiple symptoms of food hernias, often accompanied by various pathological pathologies and other diseases, cause difficulties in differential diagnosis. Hernia can differentiate with paralysis of the diaphragm, ampulla of the esophagus (phase state during its motor activity), ulcer of its distal part, cardiological pathologies: angina pectoris, ischemic heart disease, myocardial infarction. The diagnosis is specified on the basis of a more in-depth study.

Treatment of the hernia of esophagus

After the diagnosis, the doctor prescribes a suitable treatment for a particular case. Two methods of patient therapy are practiced: medicamentous and surgical. The patient is prescribed a number of drugs that neutralize the increased acidity of the stomach and envelop her mucous. If such treatment does not lead to the expected results, resort to surgery.

Medicinal treatment

For medicamentous treatment of diaphragmatic hernia use the following drugs:

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

Maalox - reduces acidity, adsorbs acid and gases, envelops mucous membranes, has a protective and analgesic effect. Produced in tablets and suspensions, packaged in sachets or bottles. Take an hour and a half after eating. One or two tablets are placed under the tongue and dissolve. The dose of the suspension is a packet or a tablespoon. Contraindicated in severe renal pathology. Possible side effects in the form of development of phosphorus deficiency;

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

Domrid - exists in tablets and suspensions. Promotes increased motility of the esophagus, stomach. Antiemetic means. It is recommended for reception for 20-30 minutes before meal: 1 tablet or the dose measured by the doctor measured by the doctor three times a day. If necessary, the dose increases, but not more than 80 mg per day. Taking the drug can cause anxiety, insomnia, headache, cramps, impaired bowel movement, heart rhythm disturbance, allergies. It is not prescribed in tablets to children under 12 years of age, patients with kidney and liver disorders, with gastrointestinal disturbances;

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

Famotidine - tablets, inhibit its secretion, reduce the activity of the enzyme pepsin. Appointed individually, on an average tablet 4 times a day. May cause dizziness, dyspepsia, increased fatigue, bronchospasm, arrhythmia. Has contraindications for pregnant women, during lactation, with allergies to components;

• proton pump inhibitors (nolpase, omeprazole, contra), their effect is similar to the previous group, but with less side effects.

Nolpaz - in the form of tablets, in the morning before ingestion one tablet is swallowed whole, the course of treatment lasts 2-4 weeks. If necessary, they can assign 2 pieces. In most cases, the drug is well tolerated, but occasionally there may be nausea, excess of the norm of liver enzymes, swelling, visual impairment. Has contraindications in case of individual intolerance, neurotic dyspepsia. It is not prescribed until age 18, pregnant and lactating women due to lack of research on the effect of the drug on this category;

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

Urochol is a drop, a herbal preparation that enhances bile secretion, which removes inflammation. Before meals, three to ten times a day, 10-20 drops drips into a small volume of water and is drunk. Up to 12 years, pregnant and lactating mothers are not recommended. Among the side effects are nausea, vomiting, allergic manifestations.

Vitamins

The hernia of the esophagus requires a balanced diet, saturated with vitamins, microelements. Food rich in vitamin A, promotes the production of glycoproteins, neutralizing the corrosive effect of hydrochloric acid in the gastric juice, and therefore help to eliminate heartburn. Butter, fish, liver, carrots, dark green greens contain this vitamin and will be useful for such a diagnosis.

Diet

Treatment is more effective when patients follow a  diet. It has a gentle nature, the essence of it is the elimination of irritation of the mucous membrane, the removal of pressure inside the peritoneum due to the small volume of consumed food, the exclusion of coarse food. Peculiarities of nutrition are the same as in gastritis with high acidity, esophagitis: it should be frequent, small portions, so that the food can go through the digestive tract without difficulty, to digest and not to return back. Unacceptable temperature contrasts are both hot and cold food. In the diet of the patient with hernias of the esophagus, such foods are included: dried rolls and bread, mucous soups (without meat, fish, mushrooms, vegetables), cereals, pasta, milk food. Cooking should be done by boiling, baking or steaming. Use sunflower and butter, remove from the diet products with coarse fiber, enhancing the formation of gas: cabbage, mushrooms, legumes, as well as fatty foods. You can eat fresh cucumber, after removing the skin from it. What you can not eat? Alcohol, sour juices, fatty, spicy, peppery, marinades do not eat, tk. They increase acidity. Fasting with a hernia of the esophagus is not recommended.

[61], [62]

Eating after operation of hiatal hernia

Nutrition after operation of hernia of the esophagus does not differ from the diet in other cavitary operations. Depending on the severity of the operation in the first days, it is even possible to feed through the probe. With a favorable development of events on the first day, it is permissible to drink only 1-1.5 glasses of water. The second shows the wiped food in the form of soups, puree low calorie, mucous broth rice, weak meat broth. Drink can be infusion of dogrose, kissel, mineral without gas or plain water. Then, add small portions of mashed cereal, steam amlets, soufflé from dietary scrolled meat, breadcrumbs of white bread of own production, increasing daily calorie content to 1500kcal. In the following six months it is necessary to adhere to the diet number 1, intended for patients with peptic ulcer of stomach, duodenum, gastritis with high acidity.

[63], [64], [65]

Daily diet menu

The diet menu for the day can be as follows:

• breakfast: milk porridge (rice, buckwheat, oatmeal, semolina), 2 boiled soft-boiled eggs, tea with milk;
• 2 breakfast: defoaming low-fat cottage cheese, sweet potato jelly;
• lunch: vegetable soup, meat steamed meatballs with mashed potatoes, baked apple;
• Afternoon snack: rose hips infusion, croutons;
• dinner: boiled fish, slimy rice garnish, tea with milk, biscuit biscuits;
• 2 hours before bedtime: a glass of warm milk.

[66]

Recipes

Some recipes for cooking dietary foods:

1. soup-mash: potatoes, carrots, zucchini cut into cubes, pick up cauliflower on inflorescences, add water, add salt and cook until ready. Using a blender to grind, add low-fat cream or butter, there is a warm;
2. steam cutlets: chicken meat, veal (in equal parts), a few oatmeal flakes, pre-filled with milk, twist, add salt, add a raw egg and form cutlets. Cooking on steam;
3. lazy vareniki: combine cottage cheese, eggs (for 0.5 kg of cottage cheese 2 eggs), sugar. Add flour until a rather thick mass is obtained. Roll out the sausage, cut with a knife into strips of 1.5 cm thick, boil in slightly salted water. There are watering with fresh, low-fat sour cream;
4. baked apples: make a groove on top of the fruit, put a teaspoon of honey and bake in the oven.

Physiotherapeutic treatment

Physiotherapy treatment involves hydrotherapy, the use of amplipulse, electrosleep, information-wave therapy, short-pulse electroneurostimulation. There is also a special gymnastics to strengthen and relax the muscles of the anterior abdominal wall. Exercises can be:

• lying on the right side (head and shoulders are raised relative to the trunk, on the pillow) when inhaling inflate the stomach, on exhalation to relax. In a week, pull the belly out while exhaling;
• kneeling on inspiration to lean to the sides, to exhale in the initial position;
• lying on his back, perform body twists, breathing in the air.

Alternative means

Alternative means of treatment of hernias most often consist in the use of medicinal herbs, helping to eliminate the main symptoms of the disease:

• when heartburn is combined the root of licorice and orange crusts, pour boiling water, allow to brew for 30 minutes, take after eating. Tea of gentian helps, infusion of flax seeds, juice from grated carrots and raw potatoes;

• with belching, they prepare an infusion of ashberry, blackberry leaves, juice from cranberry berries, honey and aloe juice;
• when the abdomen is swollen, dill water is effective (1 tablespoon of seeds per liter of boiling water, insist 3 hours, take 100g 15 minutes before meals), infusions of cumin, chamomile flowers, dandelion; brewed herbal collections of yarrow, cucumbers, St. John's wort. Another collection: peppermint, fennel fruits and valerian root;
• with constipation will help infusion of leaves of hay, buckthorn, rhubarb root, fennel, field field.

[67], [68], [69], [70]

Surgery

The operation is shown only in extreme cases, when either conservative treatment is ineffective, or a large hernia, or there are life-threatening complications, etc. The choice of a surgical method for solving the problem depends on the nature of the disease. Based on the reason for the formation of a hernia and its kind, the operation can consist of:

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

The appearance of the laparoscopic method in the 90s of the last century made it possible to conduct surgical intervention with minimal harm to the patient's health. If the rehabilitation period after abdominal surgery is almost 3 months, then after laparoscopy the patient rises already for 2-3 days, and after 3 weeks starts to work.

Prevention

Prevention of hernia of the esophagus consists in strengthening the muscles of the abdomen, in the treatment of constipation, the exclusion of lifting heavy loads, a strong cough. Important timely therapy of gastritis, duodenitis, peptic ulcer disease, chronic cholecystitis and pancreatitis. Abandonment of bad habits is also important for the prevention of pathology.

[71], [72], [73]

Forecast

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

[74], [75]