Hiatal Hernia Research Paper

Initially we were presented with a 26 year old business executive presenting with many of the symptoms of a hiatal hernia. These include heartburn, especially after meals, a dull pain behind the sternum, Pain in the back, jaws, shoulder and inner arms can also be noticed and physical activity or lying flat can agitate his pain. Additionally his postprandial (or pain after meals) was accompanied by belching (homer simpson slide)

Hiatal hernias occur when a segment of the stomach protrudes through a hole in the diaphragm and into the chest cavity. And There are 3 different presentations of hiatal hernias;

A type 1 hernia is characterised by a weakening of the phrenoesophageal membrane which allows for the oesophageal junction to migrate into the chest cavity. Note that 50% of these Type 1 hernia's occur in individuals with age 50 years or older
Type 2 hernias occur due to a defect in the junction between the oesophagus and the stomach, and they rarely present on their own.
Instead, they are observed in patients who also suffer from type 1 hiatal hernias.(change slide to show diagram) This combination of the two is known as a type 3 hiatal hernia.

In general terms, the risk of developing a hiatal hernia increases with age and weight gain. With smoking being a further contributor. According to a study by Stuciu and Bennett in, 1972, the effects of smoking significantly increased the onset of heartburn and reflux
To diagnose a hiatal hernia from the above symptoms, an x-ray could be ordered.
A positive result would reveal that the lower oesophageal sphincter is open, allowing the acidic gastric juices reflux into the lower
oesophagus.

An endoscopic biopsy or esophageal manometry test could be used to confirm this diagnosis.These reveal mucosal inflammation as well as pressure in the lower esophageal sphincter respectively. The inflammation would be a result of the hernia protruding through the diaphragm and hence the pressure would be increased not only from this but also the inflammation that inevetably occurs.

THe normal pH of the lower oesophagus is neutral, approximately 7, however individual's with a hiatal hernia usually have an acidic lower oesophagus, with a pH as low as four due to the burning of the interior wall of the oesophagus from the acid reflux. The stomach of a healthy individual has a pH of around 1.5-3.5, however somebody with a hiatal hernia such as our 26 year old executive is more likely to have a lower stomach pH. Hence, an oesophageal pH test can be used as direct evidence of Gastroesophageal Reflux Digestive Disorder - the characteristic symptom of a hiatal hernia. Further complications car arise from this altered pH. In the oesophagus ulcers, oesophagitis or scarring can occur and if the acid reaches the mouth, it can also wear down tooth enamel and result in tooth decay.

This condition is most commonly caused by weakened diaphragm muscle, can result from a congenital condition of as a result of pressure on the diaphragm from strenuous activities such as excessive coughing or vomiting and heavy lifting.

Whilst the patient is in the diagnostic process, only the symptoms of their undiagnosed hiatal hernia can be treated.

To treat gastroesophageal reflux, the patient should avoid high-fat foods because they are more challenging to digest so remain in the stomach for a longer period of time than other foods, increasing the likelihood that stomach contents will be regurgitated into the lower oesophagus. Unfortunately, chocolate and chocolate products should also be avoided as it is known that chocolate causes the diaphragm muscles to relax, increasing the severity of the hernia itself.

Gastric secretion stimulants such as caffeine and alcohol should also not be consumed as this increased the acidity of the stomach and hence increases the burning effect of the reflux.

Similarly, smoking should be avoided.

Gastroesophageal reflux can also be prevented by sleeping and sitting in a more upright position By propping the actual bed up instead of using an extra pillow, the patient is on a downward slope and gravity can help prevent reflux from occurring, hence reducing the pain associated with the symptoms

Once the diagnosis is confirmed, hiatal hernias are corrected surgically....