A hernia occurs when an organ protrudes through the muscle wall that surrounds it. A Gastrocele is a condition in which the upper part of your stomach protrudes into your chest, pushing through the small opening (or hiatus) in your diaphragm. Gastroceles are usually so small that they are not felt at all. However, if the hernia is larger, it may cause the opening in your diaphragm to expand as well. The entire stomach and other organs are in danger of sliding up into your chest at that point.
Understanding the Upper Gut
The gut (gastrointestinal tract) is the tube that runs from the mouth to the back passage (anus). The upper gut consists of the esophagus, stomach, and the first portion of the small intestine (the duodenum). Food enters the stomach via the esophagus. The stomach produces acid, which aids in the digestion of food. Food passes into the duodenum after being mixed in the stomach to be digested by the digestive system.
Muscle is found in the stomach walls. A sphincter is a thickened area of muscle located at the junction of the stomach and the esophagus. The sphincter functions as a valve. When food enters the stomach via the esophagus, the sphincter relaxes. It does, however, close at times to prevent food and acid in the stomach from refluxing into the esophagus.
The diaphragm is a large flat muscle that connects the lungs to the stomach (abdomen). It allows us to breathe easier. The esophagus enters the diaphragm through a hole (hiatus) just before joining the stomach. Normally, the entire stomach is located beneath the diaphragm. The muscle fibers in the diaphragm surrounding the lower esophagus assist the sphincter in keeping the esophagus closed to prevent acid and food reflux.
What is Gastrocele (Stomach Hernia)?
A stomach hernia is a condition in which a portion of the stomach protrudes through a diaphragm opening into the chest. The diaphragm is a muscular structure that aids in breathing and has a small opening, known as a hiatus, through which the esophagus passes before connecting to the stomach. This is referred to as the gastroesophageal junction (GEJ). The stomach pushes through that opening and into the chest in a Gastrocele, compromising the lower esophageal sphincter (LES).
The leading cause of gastroesophageal reflux disease (GERD) is LES laxity, which allows gastric content and acid to back up into the esophagus. While small stomach hernias are often asymptomatic and can be treated medically, large stomach hernias frequently necessitate surgery.
The exact number of people who have a hiatus hernia is unknown because many people do not have symptoms. They are, however, thought to be common. According to some studies, up to half of people who have indigestion tests (dyspepsia) have a hiatus hernia.
Classification of Stomach Hernias
Stomach Hernias are divided into 4 types:
- Type I (sliding type), which represents more than 95% of stomach hernias, occurs when the GEJ is displaced upwards towards the hiatus.
- Type II is a paraesophageal stomach hernia, which occurs when part of the stomach migrates into the mediastinum parallel to the esophagus.
- Type III is both a paraesophageal hernia and a sliding hernia, where both the GEJ and a portion of the stomach have migrated into the mediastinum.
- Type IV is when the stomach, as well as an additional organ such as the colon, small intestine, or spleen, also herniate into the chest.
Sliding Hiatal Hernia
When a stomach hernia involves the lower esophageal sphincter, which connects the esophagus to the stomach, the term sliding is used. A small portion of the stomach may also be involved. Heartburn and gastroesophageal reflux may occur in the patient. Because reflux can harm the lining of the esophagus, it must be treated. Medications and behavior modification, such as elevating the upper body on a pillow while sleeping, can usually be used to manage symptoms. A sliding esophageal hernia may necessitate surgery in some cases.
Paraoesophageal Hernia and Intrathoracic Stomach
The fundus, or upper portion of the stomach, may slide upward into the chest cavity through the hiatus in more severe cases of stomach hernia. The condition is caused by the worsening of a sliding stomach hernia. In rare cases, the entire stomach and even some intestines may migrate through the hiatus and rest on top of the diaphragm next to the esophagus, resulting in a condition known as giant esophageal hernia.
Stomach Hernia Causes
The precise cause of stomach hernia is unknown. The condition could be caused by a weakness in the supporting tissue. Age, obesity, and smoking all increase your risk of developing the condition. Hernias of the stomach are very common. The problem is most common in people over the age of 50.
This condition could be caused by gastric acid reflux (backflow) from the stomach into the esophagus. The majority of children with this condition are born with it (congenital). In infants, it is frequently associated with gastroesophageal reflux.
What are the symptoms of a Hiatus Hernia?
Acid reflux symptoms
The hernia does not cause any symptoms. The factors that normally prevent stomach acid from refluxing into the gullet (esophagus) may not work as well if you have a hiatus hernia. The sphincter muscle may be dysfunctional. The diaphragm muscle's normal pressure on the esophagus is lost. As a result, you are more likely to have acid in your stomach reflux into your esophagus. The acid reflux can cause inflammation of the lower esophagus. This can result in one or more of the symptoms listed below:
- Heartburn: this is the main symptom. This is a burning feeling which rises from the upper tummy (abdomen) or lower chest up towards the neck.
- Pain in the upper abdomen and chest.
- Feeling sick.
- An acid taste in the mouth.
- Difficulty swallowing.
- A burning pain when you swallow hot drinks.
These symptoms tend to come and go and are worse after eating. Some unusual symptoms may appear. If any of these symptoms appear, it can be difficult to make a diagnosis because these symptoms can mimic other conditions. For example:
- A persistent cough, especially at night, can occur. This is due to the acid reflux irritating the windpipe (trachea). Acid reflux can cause asthma-like symptoms such as coughing and wheezing.
- Other mouth and throat symptoms include gum problems, bad breath, sore throat, hoarseness, and a lump in the throat.
- In some cases, severe chest pain develops (and may be mistaken for a heart attack).
- In rare cases, symptoms of a bowel blockage can occur in people with a para-oesophageal hernia (obstructed). In this case, there would be severe tummy or chest pain, as well as retching or feeling sick (vomiting).
Many people who suffer from acid reflux do not have a hiatus hernia. Furthermore, many people with a hiatus hernia do not experience acid reflux symptoms. If you have a hiatus hernia, it does not always mean that the sphincter between the esophagus and stomach is not functioning properly. It's just that having a hiatus hernia increases your chances of having a malfunctioning sphincter and developing acid reflux symptoms.
People with a hiatus hernia who do get reflux, on average, have more severe symptoms and problems with acid reflux. This could be because, in people without a hiatus hernia, any acid that enters the esophagus is more likely to remain in contact with the lining for a longer period of time.
How is a Stomach Hernia Diagnosed?
In addition to a thorough examination and a thorough medical history, your surgeon may use one or more diagnostic tests to determine the best course of treatment.
- During a Barium Swallow / Upper GI study, you will be asked to swallow a small amount of contrast material, or liquid barium, which will coat the lining of your esophagus and allow X-ray images to be obtained. If you're having trouble swallowing, this procedure can help you find any narrowed areas in your esophagus. These are known as strictures.
- Chest X-rays: Electromagnetic energy produces images of internal tissues, bones and organs.
- CT-Scans are a series of images of the inside of your body taken from various angles to reveal a high level of detail. To ensure that your veins and organs are clearly visible in these scans, you may need to swallow a dye or have it injected into your vein.
- Upper Endoscopy (EGD): A procedure in which an endoscope is threaded through the mouth and into the esophagus. This procedure allows your surgeon to see your upper digestive tract, including your esophagus, stomach, and duodenum, or the first part of your small intestine. Your surgeon can then take a tissue sample.
What is the Best Treatment for Stomach Hernia?
Management for stomach hernias depends on the type of hernia and severity of symptoms.
- If you have reflux symptoms, you should aim to lose weight if you are overweight.
- Avoid anything that causes pressure on your stomach, such as tight clothing and corsets.
- If you are a smoker you should aim to stop. If you drink a lot of alcohol, it also helps to cut down on alcohol.
- Raising the head of your bed may help with symptoms at night.
- Avoiding eating your dinner too close to bedtime may also help with symptoms at night. Aim to have your dinner at least three hours before you go to bed ideally.
- Smaller meals may be helpful, as may avoiding foods which you find make the reflux worse.
Medicines for Stomach Hernia
A double dose of a proton pump inhibitor is given to a patient who presents with typical GERD symptoms in an outpatient setting (PPI). This can be both therapeutic and diagnostic, as persistent symptoms frequently necessitate a more thorough evaluation. The indication for surgical therapy has shifted since the introduction of PPIs. Patients with severe esophageal injury, such as ulcers, strictures, or Barrett's mucosa, should be considered for surgery.
Other patients, such as those who have had symptoms for a long time or who have had partial relief while on medical therapy, should also be considered for surgical intervention. The cost of surgery has decreased due to advancements in minimally invasive techniques for the treatment of GERD. Surgical therapy may be considered the treatment of choice for patients with a life expectancy of more than 8 years who require lifelong therapy due to a mechanically defective LES.
Surgical Management of Stomach Hernia
Due to the laxity of the stomach's peritoneal attachments and subsequent rotation of the gastric fundus, paraoesophageal hernias can present with a gastric volvulus. This is classified as a surgical emergency. Current guidelines recommend operative repair of all symptomatic paraesophageal hernias as well as completely asymptomatic large hernias in patients under the age of 60 who are otherwise healthy.
Nissen fundoplication (360-degree wrap):
This entails completely wrapping the GEJ with the stomach fundus. This is typically done with a 52 French bougie in place to ensure proper approximation without overstretching the wrap. To mobilize the fundus, the short gastric vessels are dissected off the greater curvature of the stomach. The phrenoesophageal membrane is fully dissected over the left crus, and the crural fibers are identified.
The lesser omentum must be opened and the right phrenoesophageal membrane mobilized before performing the right crural dissection. During this dissection, the anterior and posterior vagi must be preserved. A Penrose drain is usually placed around the esophagus to help with mobilization and wrap formation. 3-4 interrupted permanent sutures are used to create the wrap over a length of 2.5 to 3 cm. The 52 French bougie is removed once the wrap is finished, and the wrap is anchored to the esophagus and hiatus. This aids in the prevention of herniation and slippage.
Partial fundoplication (Dor and Toupet):
When esophageal motility is poor, a partial fundoplication is usually recommended. The Dor procedure, which is an anterior wrap, and the Toupet procedure, which is a posterior wrap, are the two most common partial fundoplications. In contrast to the Nissen's complete 360-degree wrap, these two procedures involve creating a 180 to 250-degree wrap. When motility is an issue, it is thought that a partial wrap will help prevent obstruction in the esophagus.
As with the 360-degree wrap, this is accomplished by folding the fundus over the anterior aspect of the esophagus and then anchoring it to the hiatus and esophagus. This wrap has been used sparingly to treat GERD and is more commonly used to treat patients with achalasia who have had an anterior myotomy.
The entire esophageal dissection for this procedure is the same as for a Nissen, with the esophagus mobilized. This procedure, as opposed to the Nissen, creates a 220 to 250-degree wrap around the posterior aspect of the esophagus and is the procedure of choice if motility is an issue.
Minimally Invasive Hernia Repair
Minimally invasive surgery can reduce the size of a hernia as well as the opening in the diaphragm, preventing strangulation. Surgeons will insert a tiny video camera into your abdomen during this procedure. They'll be able to see images projected onto a monitor, giving them more control and finesse during the procedure. The goal of this surgery is to reconnect your stomach to your abdomen and close the hole in your diaphragm. Minimally invasive surgery has been linked to a faster recovery and return to function than traditional open repair. If you are a candidate for this approach, your doctor will determine.
The differential diagnosis of a patient with GERD can be quite extensive, which is why such a thorough work-up is performed prior to operative therapy. Heartburn is commonly described as an epigastric caustic or burning sensation. This does not usually radiate to the back or be described as a pressure sensation. This is an important part of the history and physical because it can differentiate GERD from other pathologies like pancreatitis or acute coronary syndrome.
GERD extra-esophageal symptoms manifest as laryngeal or pulmonary symptoms and arise from the respiratory tract. It can be difficult to distinguish the cause of such symptoms, so keep an eye out for primary esophageal motility disorders, gastric or esophageal cancer, and primary lung disease. If a patient presents with such symptoms and the primary work-up is negative, it is critical to look into other possible causes. Consultation with a pulmonologist is frequently required.
Prognosis of Gastrocele
The relief of symptoms, improvement in esophageal acid exposure, complications, and need for reoperation are all indicators of the success of gastrocele surgery. Over the course of ten years, one prospective study followed 100 patients who had antireflux surgery. After ten years, they discovered a 90% reduction in symptoms. Over the last two decades, collective operative management experience has continued to improve outcomes. Symptom improvement has increased with experience, while perioperative complications have decreased. This is especially true in high-traffic areas.
What are the Possible Complications of a Stomach Hernia?
Possible complications may occur if you have long-term reflux of acid into the gullet (esophagus), which occurs in some cases. These include:
- Oesophagitis :This is an inflammation of the lining of the gullet, caused by the acid washing against it over time. This can usually be treated with PPIs as mentioned above.
- Cough: Acid reflux can sometimes cause the voice box area (larynx) to swell and cause a tickly cough. This is usually successfully treated with anti-reflux medications.
- Narrowing (a stricture): Scarring and narrowing of the lower esophagus can result from severe and long-term inflammation. This is unusual.
- Twisting (volvulus) : This is also referred to as a strangulated hernia (trapping of the hernia with blockage of the blood supply). This is an uncommon complication associated with the uncommon para-oesophageal type of hiatus hernia.
- Barrett's esophagus: The lining of the esophagus is composed of a number of units known as cells. The cells that line the lower esophagus change in Barrett's esophagus. The altered cells are more likely to become cancerous than usual.
- Cancer: If you have long-term acid reflux, your risk of developing esophageal cancer is slightly increased compared to the normal risk. This slight increase in risk is even greater in people who have both reflux and a hiatus hernia. This is because, on average, people with a hiatus hernia have more severe reflux problems than those without a hiatus hernia.
A gastrocele is a condition in which the upper part of your stomach bulges through a diaphragmatic opening. The diaphragm is a thin muscle that connects your chest to your abdomen. Your diaphragm works to keep acid from entering your esophagus. When you have a gastrocele, the acid comes up more easily. The leaking of stomach acid into the esophagus is known as gastroesophageal reflux disease (GERD). If your hiatal hernia does not cause any symptoms or problems, you do not require treatment. If you do experience symptoms, some lifestyle changes may be beneficial.