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Heartburn, Acid Reflux & Hiatal Hernia

Hernia:  protrusion of a portion of an organ or tissue through an abnormal opening.

Inguinal hernia:  the large or small intestine, omentum, or bladder protrudes into the inguinal (pertaining to the groin) canal.  Inguinal hernia may be reducible - if the hernia can be moved back into place easily, and incarcerated - if it can't be reduced because of adhesions in the hernial sac, or strangulated - if part of the herniated intestine becomes twisted or edematous, cutting off normal blood flow and peristalsis and may lead to intestinal obstruction and necrosis.  Inguinal hernia can be direct or indirect.  Indirect:  it causes the abdominal viscera to protrude through the inguinal ring and follow the spermatic cord (in males) or round ligament (in females).
Direct:  it results from a weakness in the fascial floor of the inguinal canal.

Cause:  results from abdominal muscles  weakened by congenital malformation, traumatic injury, aging, or from increased intra abdominal pressure - usually due to heavy lifting, pregnancy, obesity, or straining.


May have diarrhea (possible strangulation)
Lump that appears over the herniated area when the patient stands or strains and disappears when the patient is supine.


Reducible hernia:  may be relieved temporarily by moving the hernia back into place.
A truss may keep the abdominal contents from protruding into the hernial sac (Note- this is not a cure, this device is beneficial for an elderly or debilitated patient, for whom any surgery is potentially hazardous)

Herniorrhaphy is a surgical treatment preferred for infants, adults, and otherwise healthy elderly patients.  This surgery replaces hernial sac contents into the abdominal cavity and seals the opening.

Hernioplasty:  this is another effective procedure, which reinforces the weakened area with steel mesh, fascia, or wire.

For strangulated or necrotic hernia:  the patients requires bowel resection.  an extensive resection may required temporary colostomy though it is rare.



Hiatal Hernia This is a structural defect in which a weaned diaphragm allows a portion of the stomach to pass through the esophageal diaphragmatic opening (hiatus) into the chest when intra abdominal pressure increases.

There are three types of hiatal hernia:  Sliding hernia which is the most common.  Paraesoophageal (rolling) hernia, and mixed hernia, which includes features of the others.  In sliding hernia:  both the stomach and the gastroesophageal junction slip up into the chest so that the gastroeal junction is above the diaphragmatic hiatus.  In a paraesoophageal hernia:  a part of the greater curvature of the stomach rolls through the diaphragmatic defect.

Cause:  May be caused by muscle weakening associated with the following:
Aging, esophageal carcinoma, kyphoscoliosis, trauma, certain surgical procedures, and congenital diaphragmatic malformations.


In a sliding hiatal hernia:  occur in the presence of an incompetent gastroesophageal sphincter.  --Heartburn - occurring 1 to 4 hours after eating and is aggravated by increased intra abdominal pressure.  May experience vomiting or regurgitation. 

Retrosternal or substernal chest pain.  Usually occurring often after meals or at bedtime and is aggravated by reclining, belching, and increased intra abdominal pressure.

In a paraesophageal hiatal hernia:  the patient may be asymptomatic.  He may have a feeling of fullness in the chest or pain resembling angina pectoris.


Treatment is to modify or reduce reflux by changing the quantity or quality of gastric contents, by strengthening the gastroesophageal sphincter muscle pharmacologically, or by decreasing the amount of reflux through gravity.


Drug therapy to strengthen gastroesophageal sphincter tone may include a cholinergic agent such as bethanechol.  Metoclopramide has also been used to stimulate smooth muscle contraction, increase sphincter tone, and decrease reflux after eating.

If above treatment fails to control symptoms, the patient may require surgical repair.  A paraesophageal hiatal hernia, even one that causes no symptoms, needs surgical treatment because of the high risk of strangulation.  Techniques vary greatly, but most create an artificial closing mechanism at the gastroesophageal junction to strengthen the lower esophageal sphincter's barrier function.  The surgeon may use an abdominal or a thoracic approach.

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