Materiały źródłowe

• #1 Hiatal Hernia – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK562200/

  A hiatal hernia is a common condition characterized by the abnormal protrusion of the upper part of the stomach or other internal organs through the diaphragm’s hiatus. The development of a hiatal hernia is multifactorial, with contributing factors including congenital anatomical defects, increased intraabdominal pressure (as seen in obesity, pregnancy, and chronic coughing), and age-related changes in the diaphragm’s muscle tone. […] Hiatal hernias may be congenital or acquired. The condition’s prevalence is increased among older people. Muscle weakness due to age-related loss of flexibility and elasticity is believed to be a predisposing factor to the development of a hiatal hernia. The hernia may prevent the upper part of the stomach from returning to its natural position below the diaphragm during swallowing. Other predisposing factors have been identified, such as elevated intraabdominal pressure, which typically arises from obesity, pregnancy, chronic constipation, and chronic obstructive pulmonary disease (COPD). Trauma, age, previous surgeries, and genetics also play a role in the development of a hiatal hernia.

• #2 Hiatal Hernia: Practice Essentials, Background, Pathophysiology

  https://emedicine.medscape.com/article/178393-overview

  A hiatal hernia occurs when a portion of the stomach prolapses through the diaphragmatic esophageal hiatus. […] The diaphragmatic hiatus itself is approximately 2 cm in length and chiefly consists of musculotendinous slips of the right and left diaphragmatic crura arising from either side of the spine and passing around the esophagus before inserting into the central tendon of the diaphragm. […] The presence of a hiatal hernia compromises this reflux barrier not only in terms of reduced LES pressure but also reduced esophageal acid clearance. Patients with hiatal hernias also have longer transient LES relaxation episodes particularly at night time. These factors increase the esophageal mucosa acid contact time predisposing to esophagitis and related complications. […] Sliding hiatal hernia by far is the most common type of hiatal hernia. It occurs when the gastroesophageal junction, along with a portion of the stomach, migrates into the mediastinum through the esophageal hiatus. […] In paraesophageal hernia, also called rolling-type hiatal hernia, the widened hiatus permits the fundus of the stomach to protrude into the chest, anterior and lateral to the body of the esophagus; however, the gastroesophageal junction remains below the diaphragm.

• #3 Hiatus Hernias | Sliding, Rolling | Treatment – RefluxUK

  https://refluxuk.com/diagnosis/hiatus-hernia

  Gastroesophageal Reflux Disease (GERD) can be either primary or secondary. […] Hiatus hernias are probably the main cause of GORD as they cause failure of the LOS. […] A hiatus hernia occurs when the soft tissues around the crura and the muscles themselves become weak. Research has shown that there are often identifiable biochemical and associated genetic abnormalities in the tissues around the crura that cause them to deteriorate. […] As a consequence of these weaknesses the usual connections between the crura and the oesophagus decay and in due course the gap between the crura, the hiatus, enlarges. […] Once the sling fibres of the oesophagus are no longer augmented by the crura, the LOS almost always becomes weak and incompetent. […] The LOS relies on the crura. Without repair it wont work properly.

• #4 | General Surgeon & Foregut Surgeon located in Lone Tree, CO | Institute of Esophageal and Reflux Surgery

  https://www.iersurgery.com/content/large-hiatal-hernia-paraesophageal-hernia

  A hiatal hernia occurs when the upper part of the stomach goes up through the opening in the diaphragm (the muscle that separates the chest and the abdomen) that is normally occupied by the esophagus. […] The drawings below illustrate how the development of a hiatal hernia leads to unfolding of the valve mechanism, resulting in a funnel-shaped valve that increases the ability of stomach contents to reflux back into the esophagus (large arrow on right). […] For the most part, hiatal hernias weaken the effectiveness of the antireflux barrier and increase the severity of gastroesophageal reflux disease. […] The diaphragm helps the valve between the stomach and esophagus work. It is common in people with a hiatal hernia to experience reflux as the valve cannot work as well. […] Recent studies have shown a collagen defect in the diaphragm in patients with a hiatal hernia. Over time, and as we age, our tissues become weaker, causing a small hernia can become a larger hernia.

• #5 Hiatal hernia, lower esophageal sphincter and their combined effect on the natural history of gastroesophageal reflux disease: implications for surgical therapy – Manzo – Annals of Laparoscopic and Endoscopic Surgery

  https://ales.amegroups.org/article/view/6141/html

  The modern surgical therapy of gastroesophageal reflux disease (GERD) is based upon the concept that the antireflux barrier has two components that form a double-sphincter and work synergistically to protect from reflux of gastroduodenal contents: the lower esophageal sphincter (LES) and the crural diaphragm. Factors implicated in the pathogenesis of hiatal hernia (HH) are the thoraco-abdominal pressure gradient, the esophageal shortening secondary to reflux-induced fibrosis, and the hiatal enlargement due to peri-esophageal tissue deterioration. […] The main factors implicated in the pathogenesis of HH are the thoraco-abdominal pressure gradient, the esophageal shortening secondary to reflux-induced fibrosis, and the hiatal enlargement due to tissue deterioration. The esophageal hiatus represents a locus minoris resistentiae of the diaphragm which is subjected to continuous mechanical stress.

• #6 Hiatus hernia pathophysiology – wikidoc

  https://www.wikidoc.org/index.php/Hiatus_hernia_pathophysiology

  It is understood that hiatus hernia is the result of either decreased elastin of phrenoesophageal membrane due to aging or imbalance in pressure gradient between intra-abdominal pressure and intra-thoracic pressure leading to the esophagogastric junction being displaced into normal hiatus. […] A rise in intra-abdominal pressure and fall in intra-thoracic pressure may lead to development of hernia. […] The symptoms in hiatus hernia are the result of reflux esophagitis and the mechanisms involved include: Low resting LES pressure, Prolonged time taken to clear acid, Delayed gastric emptying, Transient LES relaxation which occurs more frequently in hiatus hernia. […] The pathophysiology of hiatus hernia depends on the histological subtype: Paraesophageal hernia are less common and have lower incidence of gastroesophageal reflux disease. […] The hiatus hernia reduces LES sphincter.

• #7 Hiatal hernia, lower esophageal sphincter and their combined effect on the natural history of gastroesophageal reflux disease: implications for surgical therapy – Manzo – Annals of Laparoscopic and Endoscopic Surgery

  https://ales.amegroups.org/article/view/6141/html

  Besides the loss of tensile strength of the muscular crura and the loss of elasticity of the phreno-esophageal ligament, an additional factor that may account for progressive HH is the acquired esophageal shortening secondary to gastroesophageal reflux causing sustained contraction of the longitudinal esophageal muscle and fibrosis. […] The clinical relationship between HH and GERD has been extensively documented in epidemiological and clinical studies. Patients with HH are more likely to present with reflux symptoms, and the prevalence of GERD can reach 94%; on the other hand, symptomatic GERD patients are more likely to have HH compared to those without symptoms. […] The failure of the antireflux barrier and consequent increase of esophageal acid exposure is secondary to incompetence of the crural diaphragm, with lack of pinchcock effect, incompetence of the LES, characterized by low basal pressure, short total length and/or intra-abdominal length, and reduced esophageal acid clearance caused by outlet obstruction and impairment of reflux-induced primary peristalsis. […] The results of this review suggest that the pathogenesis of HH is multifactorial and correlates with progression of GERD. Physiologic aging combined with metabolic, genetic and mechanical factors play an important role in the natural history of the disease.

• #8 Hiatal hernia – epidemiology, pathogenesis, diagnostic • Postępy Nauk Medycznych 5/2018 • Czytelnia Medyczna BORGIS

  https://www.czytelniamedyczna.pl/6473,hiatal-hernia-epidemiology-pathogenesis-diagnostic.html

  Hiatal hernia may be congenital or acquired. Among acquired hiatal hernias, traumatic and nontraumatic are distinguished. The most common types of hernia are acquired in non-traumatic manner. Nontraumatic acquired hernias are divided into four subtypes: sliding (type I) and paraoesophageal (type II). Mixed type with coexisting features of sliding and paraoesophageal hernia are also observed (type III). IV type of hiatal hernia is connected with short esophagus. Sliding hiatal hernia is most common type of hiatal hernia. It occurs when the gastro-esophageal junction, along with the part of the stomach, migrates to the mediastinum through the esophagus. In the majority of patients with esophageal hernia, no symptoms are observed, in part of patients symptoms of reflux are visible. This type of hernia interferes with the anti-reflux barrier mechanisms in several ways. The lower esophageal sphincter (LES) relocates from an area with positive pressure inside the abdominal cavity to the area of low pressure in the thorax, which interferes with the activity of the sphincter. What is more, the relaxation of diaphragm crura reduces the anti-reflux barrier of the esophagus. The Hiss angle is lost in the diaphragmatic hernia, which causes higher risk of regurgitation of gastric contents. These changes, not only predispose to reflux of gastric contents to the esophagus, but also prolong the time of acid contact with the esophageal epithelium.

• #9 Hiatal hernia – Wikipedia

  https://en.wikipedia.org/wiki/Hiatal_hernia

  A hiatal hernia or hiatus hernia is a type of hernia in which abdominal organs (typically the stomach) slip through the diaphragm into the middle compartment of the chest. This may result in gastroesophageal reflux disease (GERD) or laryngopharyngeal reflux (LPR) with symptoms such as a taste of acid in the back of the mouth or heartburn. Other symptoms may include trouble swallowing and chest pains. Complications may include iron deficiency anemia, volvulus, or bowel obstruction. […] The most common risk factors are obesity and older age. Other risk factors include major trauma, scoliosis, and certain types of surgery. […] The diagnosis may be confirmed with endoscopy or medical imaging. Endoscopy is typically only required when concerning symptoms are present, symptoms are resistant to treatment, or the person is over 50 years of age.

• #10 Hiatus hernias and the Hill classification – Endoscopy Campus

  https://www.endoscopy-campus.com/en/classifications/hiatus-hernias-and-the-hill-classification/

  Herniation of the stomach through the esophageal hiatus into the mediastinum is known as hiatus hernia. […] The prevalence of the condition increases with increasing age and when there is raised intra-abdominal pressure (e.g., in obesity or pregnancy). […] Male sex is also a risk factor for the presence of hiatus hernia. […] Depending on its severity, it can cause spatial dissociation of the complex sphincter muscle apparatus, consisting of the diaphragmatic crura and smooth-muscle wall of the cardia. […] This can lead to insufficiency of sphincter muscle function in the area of the lower esophageal sphincter. […] Axial hiatus hernia may be, but is not necessarily, associated with gastroesophageal reflux disease. […] An indication for treatment of axial hiatus hernia is only present when there is functional evidence of reflux disease, secondary disturbance of esophageal motility, or volume reflux.

• #11 Clinical Significance of Hiatal Hernia

  https://www.gutnliver.org/journal/view.html?volume=5&number=3&spage=267

  The mechanism of reflux due to GEJ incompetence can be summed down to three: 1) tLESRs, 2) hypotensive LES, and 3) anatomical defect such as hiatal hernia. […] Hiatal hernia is a condition in which parts of the abdominal contents, mainly the GEJ and the stomach, are proximally displaced above the diaphragm through the esophageal hiatus into the mediastinum. […] Loss of elasticity of the phrenoesophageal ligament/membrane may also be caused by excessive contraction of the esophageal longitudinal muscle, increased abdominal pressure as occurs in power athletes, pregnancy, genetic predisposition, and previous surgery. […] The significance of sliding hiatal hernia is its relation with GERD in which the symptoms worsen with increasing size of the sliding hiatal hernia. […] The presence of hiatal hernia per se is not an indication for treatment, and therapy should be given to those with symptoms attributable to this condition. […] The treatment of a hiatal hernia is similar to the management of GERD and should be reserved for those with symptoms attributable to this condition.

• #12 Hiatal hernia – Symptoms and causes – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/hiatal-hernia/symptoms-causes/syc-20373379

  A hiatal hernia occurs when the upper part of the stomach bulges through the diaphragm into the chest cavity. […] A hiatal hernia happens when the upper part of the stomach bulges through the large muscle that separates the abdomen and the chest. The muscle is called the diaphragm. […] A hiatal hernia occurs when weakened muscle tissue allows your stomach to bulge up through your diaphragm. It’s not always clear why this happens. But a hiatal hernia might be caused by: Age-related changes in your diaphragm. Injury to the area, for example, after trauma or certain types of surgery. Being born with a very large hiatus. Constant and intense pressure on the surrounding muscles. This can happen while coughing, vomiting, straining during a bowel movement, exercising or lifting heavy objects.

• #13 Diet for Hiatal Hernia Prevention

  https://nutritionfacts.org/video/diet-and-hiatal-hernia/

  Straining at stool over time may force part of the stomach up into the chest, contributing to GERD acid reflux disease. […] Hiatus hernia occurs when part of the stomach is pushed up through the diaphragm into the chest cavity, which makes it easy for acid to reflux up into the esophagus and throat. […] A simple model may help illustrate the mechanism producing upward herniation of the stomach through the hole in the diaphragm, which separates the abdomen from the chest, called the esophageal hiatus. […] When we bear down and strain at stool, its like squeezing our abdomen, and may herniate part of our stomach up. […] Consistent with this concept is the observation that in Africans the lower esophageal sphincter is entirely sub-diaphragmatic, whereas it usually straddles the diaphragm in Westerners, and is above the diaphragm in the presence of hiatus hernia. […] And the same abdominal pressure from straining that may cause hiatal hernias may cause a number of other problems.

• #14 Hiatus Hernia – Gastrointestinal Disorders – Merck Manual Professional Edition

  https://www.merckmanuals.com/professional/gastrointestinal-disorders/esophageal-and-swallowing-disorders/hiatus-hernia

  Etiology of hiatus hernia is usually unknown, but a hiatus hernia is thought to be acquired through stretching of the fascial attachments between the esophagus and diaphragm at the hiatus (the opening through which the esophagus traverses the diaphragm). […] There are 2 main types of hiatus hernia: […] A sliding hiatus hernia is a common incidental finding on radiograph; therefore, the relationship of hernia to symptoms is unclear. Although most patients with gastroesophageal reflux disease (GERD) have some degree of hiatus hernia, 50% of patients with hiatus hernia have GERD. […] A paraesophageal hiatus hernia is generally asymptomatic but, unlike a sliding hiatus hernia, may incarcerate and strangulate. Occult or massive gastrointestinal hemorrhage may occur rarely with either type. […] An asymptomatic sliding hiatus hernia requires no specific therapy (1). For patients with accompanying GERD, therapy with a proton pump inhibitor should be considered. […] For a paraesophageal hernia, repair should be considered because of the risk of strangulation.

• #15 Hiatal hernia – Wikipedia

  https://en.wikipedia.org/wiki/Hiatal_hernia

  The diagnosis of a hiatal hernia is typically made through an upper GI series, endoscopy, high resolution manometry, esophageal pH monitoring, and computed tomography (CT). […] A type I hernia, also known as a sliding hiatal hernia, occurs when part of the stomach slides up through the hiatal opening in the diaphragm. There is a widening of the muscular hiatal tunnel and circumferential laxity of the phrenoesophageal ligament, allowing a portion of the gastric cardia to herniate upward into the posterior mediastinum. […] A type II hernia, also known as a paraesophageal or rolling hernia, occurs when the fundus and greater curvature of the stomach roll up through the diaphragm, forming a pocket alongside the esophagus. […] Type III hernias have elements of both types I and II hernias. With progressive enlargement of the hernia through the hiatus, the phrenoesophageal ligament stretches, displacing the gastroesophageal junction above the diaphragm, thereby adding a sliding element to the type II hernia.

• #16 Atypical and typical manifestations of the hiatal hernia – Goodwin – Annals of Laparoscopic and Endoscopic Surgery

  https://ales.amegroups.org/article/view/6254/html

  Hiatal hernia is a common disorder characterized by protrusion of abdominal contents through the hiatus of the diaphragm and into the mediastinum. The condition usually involves the gastroesophageal junction (GEJ), but may include any abdominal structure. The extent of gastric and GEJ involvement, as well as herniation of additional abdominal organs through the hiatus, has evolved into the anatomical classification of hiatal hernias from types I through IV. In type I hernias, the GEJ migrates above the diaphragm into the mediastinum with the fundus and remaining stomach inferior to the GEJ. Type 1 hernias are referred to as sliding hiatal hernias and account for more than 95% of hiatal hernias. The remaining categories of hiatal hernias, types II though IV, are paraesophageal hernias. In type II hernias, the GEJ remains in the normal anatomical position with the fundus herniating cephalad though the hiatus. Type III hernias are a combination of types I and II and account for more than 90% of paraesophageal hernias. With type IV hiatal hernias, additional abdominal structures other than the stomach are herniated though the hiatus. The clinical manifestations of hiatal hernias vary and are impacted by the type and size of the hernia.

• #17 Hiatus hernia – UpToDate

  https://www.uptodate.com/contents/hiatus-hernia

  Hiatus hernia is a frequent finding by both radiologists and gastroenterologists. This topic will review the classification, pathogenesis, clinical manifestations, diagnosis, and management of a hiatus hernia. […] Hiatus hernia refers to herniation of elements of the abdominal cavity through the esophageal hiatus of the diaphragm. Hiatus hernias are broadly divided into sliding and paraesophageal hernias (figure 1). The most comprehensive classification scheme recognizes four types of hiatus hernia. […] A paraesophageal hernia is a true hernia with a hernia sac composed of peritoneum. It is characterized by an upward dislocation of the gastric fundus through a focal defect in the phrenoesophageal membrane. […] Type II hernias result from a localized defect in the phrenoesophageal membrane, where the gastric fundus serves as a lead point of herniation while the EGJ remains fixed to the preaortic fascia and the median arcuate ligament.

• #18 Hiatal hernia – Wikipedia

  https://en.wikipedia.org/wiki/Hiatal_hernia

  Type IV hiatus hernia is associated with a large defect in the phrenoesophageal ligament, allowing other organs, such as colon, spleen, pancreas and small intestine to enter the hernia sac. […] In some unusual instances, as when the hiatal hernia is unusually large, or is of the paraesophageal type, it may cause esophageal stricture or severe discomfort. About 5% of hiatal hernias are paraesophageal. If symptoms from such a hernia are severe for example if chronic acid reflux threatens to severely injure the esophagus or is causing Barrett’s esophagus, surgery is sometimes recommended.

• #19 Massive hiatal hernia involving prolapse of the entire stomach and pancreas resulting in pancreatitis and bile duct dilatation: a case report | Surgical Case Reports | Full Text

  https://surgicalcasereports.springeropen.com/articles/10.1186/s40792-020-0773-8

  In type IV HH cases, pancreatic herniation is a rare phenomenon, because the head segment of the pancreas and duodenum are positioned in the retroperitoneum and fixed by Treitz ligament. […] However, extension of the transverse mesocolon owing to the increase in intra-abdominal pressure induces loosening of the posterior fascia, which results in mobilization and herniation into the chest. […] The diagnosis is confirmed by elevation of pancreatic enzyme and imaging finding of pancreatic herniation with inflammatory reaction secondary to pancreatitis (peripancreatic fluid collections, interstitial edematous, stranding of mesenteric fat). […] Although it is difficult to clearly prove that herniation of pancreas was the primary pathogenesis of acute pancreatitis, most cases were diagnosed based on the exception of other common pathogenesis for acute pancreatitis, such as gallstone, choledocholithiasis, and alcohol. […] Considering the serious complications of type IV HH, patients must be followed closely and undergo surgical repair early, after controlling the pancreatic inflammation, before serious complications occur.

• #20 A new mechanism of gastroesophageal reflux in hiatal hernia documented by high-resolution impedance manometry: a case report

  https://pmc.ncbi.nlm.nih.gov/articles/PMC5049569/

  Gastroesophageal reflux disease (GERD) is recognized to be a multifactorial disease and several mechanisms leading to reflux have been described, nevertheless its pathophysiology has not been fully clarified. Hiatus hernia is a known risk factor for GERD since it impairs the esophagogastric junction, leading to: reduction in lower esophageal sphincter pressure; increase in the frequency of the transient lower esophageal sphincter relaxation; and impairment of esophageal clearance. […] Hiatus hernia (HH) interferes with the anatomy and physiology of the normal anti-reflux barrier through several mechanisms, such as: reduction in lower esophageal sphincter (LES) pressure; increase in the frequency of the transient LES relaxation (TLESR); and impairment of esophageal clearance. […] HH causes an anatomical and physiological interference in the normal anti-reflux barrier with several mechanisms: it reduces LES length and pressure, impairs the augmenting effects of the diaphragmatic crus, is associated with decreased esophageal peristalsis, increases the cross-sectional area of the esophagogastric junction (EGJ), and acts as a reservoir allowing reflux from the hernial sac into the esophagus during swallowing.

• #21 Clinical Significance of Hiatal Hernia

  https://www.gutnliver.org/journal/view.html?volume=5&number=3&spage=267

  The relationship between hiatal hernias and gastroesophageal reflux disease (GERD) has been greatly debated over the past decades, with the importance of hiatal hernias first being overemphasized and then later being nearly neglected. It is now understood that both the anatomical (hiatal hernia) and the physiological (lower esophageal sphincter) features of the gastroesophageal junction play important, but independent, roles in the pathogenesis of GERD, constituting the widely accepted „two-sphincter hypothesis.” […] The gastroesophageal junction becomes incompetent and esophageal acid clearance is compromised in patients with hiatal hernia, which facilitates the development of GERD. Of the different types of hiatal hernias (types I, II, III, and IV), type I (sliding) hiatal hernias are closely associated with GERD.

• #22 Clinical Significance of Hiatal Hernia

  https://www.gutnliver.org/journal/view.html?pn=vol&uid=284&vmd=Full

  The mechanism of reflux due to GEJ incompetence can be summed down to three: 1) tLESRs, 2) hypotensive LES, and 3) anatomical defect such as hiatal hernia. […] In hiatal hernia, the LES is displaced proximally, and this leads to spatial separation of the intrinsic LES from the extrinsic compression by the diaphragm, which results in decreased resting LES pressure in proportion to the size of the hiatal hernia. […] The proximal displacement of the LES in hiatal hernia further compromises the competence of the GEJ due to the loss of the intra-abdominal segment of the LES, because the intra-abdominal location of the LES per se is considered to serve as a valve by being exposed to the positive abdominal pressure. […] Loss of the acute angle of His in hiatal hernia is also thought to add to the incompetence of GEJ possibly due to the compromise of the flap valve effect of the structure.

• #23 Pathophysiology of Gastroesophageal Reflux Disease and Hiatal Hernia | Pearson’s General Thoracic

  https://ebook.sts.org/sts/view/Pearsons-General-Thoracic/1418525/3.1/Pathophysiology_of_Gastroesophageal_Reflux_Disease_and_Hiatal_Hernia

  Transient lower esophageal sphincter relaxation (TLESR) is a dominant mechanism of lower esophageal sphincter (LES) dysfunction leading to gastro-esophageal reflux disease (GERD). […] Hiatal hernia (HH) contributes to the formation, size, and position of the acid pocket. […] Axial HHs, characterized by the permanent supra-diaphragmatic migration of the E-G junction contribute to the impairment of cardia continence. […] The influence of HH on the clinical presentation of GERD, according to various pathophysiological mechanisms, must be carefully investigated. […] While pathophysiological studies refer generally to HH, the surgical literature tends to distinguish between axial HH (reducible or non-reducible) and non-axial HH in consideration of the different clinical and pathophysiological characters of different types of HH and of the necessity to tailor the surgical technique according to the anatomy of hernia and diaphragmatic hiatus.

• #24 Hiatus hernia : GI Motility online

  https://www.nature.com/gimo/contents/pt1/full/gimo48.html

  In contrast, patients with hiatal hernia may exhibit preexisting compromise of the hiatal sphincter. […] Acquired anatomic changes attributable to hiatus hernia may alter the compliance at the relaxed EGJ, thereby decreasing the resistance to gastroesophageal flow. […] Once the hiatus is physiologically disrupted, it is no longer protective in preventing gastroesophageal reflux. […] The defining abnormality with esophagitis is excessive mucosal acid exposure, which, in turn, is dependent on both the frequency of reflux events and the time required to achieve acid clearance for each event. […] The variable associated with the greatest impairment of esophageal acid clearance was hiatus hernia. […] The mechanisms by which hiatus hernia compromises fluid emptying from the distal esophagus have been explored. […] Re-reflux occurs predominantly during inspiration and can be attributed to loss of the normal one-way valve function of the crural diaphragm.

• #25 A new mechanism of gastroesophageal reflux in hiatal hernia documented by high-resolution impedance manometry: a case report

  https://pmc.ncbi.nlm.nih.gov/articles/PMC5049569/

  The most probable hypothesis could be that reflux is due to a transient increase in hernial sac pressure: the hernial sac acts as a reservoir increasing its pressure to overcome the basal LES pressure. As a consequence, the gastric content could reflux from the hernial sac into the esophagus, not during swallowing phase like Gordon et al proposed, but after the end of each peristaltic wave until the following swallow. The mechanism we have described may be similar to what happens in the acid pocket of patients with HH, with the difference that in our case reflux occurs even in absence of TLESRs and with a perfectly working LES, despite HH.

• #26 Hiatus hernia : GI Motility online

  https://www.nature.com/gimo/contents/pt1/full/gimo48.html

  Hiatal hernia generally denotes upward displacement of the stomach through the diaphragmatic esophageal hiatus into the thoracic cavity. […] Sliding hiatal hernias contribute to gastroesophageal reflux through several different mechanisms and they also impair esophageal emptying. […] The key abnormalities in the pathogenesis of GERD are reflux of acid and pepsin from the stomach into the esophagus and a reduction in the effectiveness of esophageal acid clearance. […] Mechanistic studies of reflux disease have revealed three dominant patterns of EGJ incompetence: (1) transient LES relaxations, (2) hypotensive LES, and (3) anatomic disruption of the EGJ associated with a hiatal hernia. […] Patients with a normal EGJ require inhibition of both the intrinsic LES and extrinsic crural diaphragm for reflux to occur; physiologically this occurs only in the setting of a TLESR.

• #27 Atypical and typical manifestations of the hiatal hernia – Goodwin – Annals of Laparoscopic and Endoscopic Surgery

  https://ales.amegroups.org/article/view/6254/html

  The associations between hiatal hernia and reflux symptoms, reflux esophagitis, stricture, Barretts esophagus, and esophageal malignancy are due to disruptions of different antireflux mechanisms and increased esophageal acid exposure resulting from a hiatal hernia. […] As previously discussed, hiatal hernias disrupt different antireflux mechanisms which lead to the strong association between hiatal hernia and typical and atypical manifestation of GERD. Furthermore, the mere presence of a hiatal hernia can produce a number of typical and, less commonly, atypical gastrointestinal symptoms and complications, unrelated to reflux. These symptoms result from the physical herniation of the stomach and additional abdominal structures through the hiatus. Hiatal hernias can disturb gastrointestinal filling, receptive relaxation, or continuity and produce various gastrointestinal obstructive symptoms.

• #28 Atypical and typical manifestations of the hiatal hernia – Goodwin – Annals of Laparoscopic and Endoscopic Surgery

  https://ales.amegroups.org/article/view/6254/html

  Typical obstructive gastrointestinal symptoms of a hiatal hernia include early satiety, nausea, and bloating. These symptoms can be exacerbated with oral intake. […] Atypical gastrointestinal obstructive manifestations of a hiatal hernia occur with less frequency. Progressive herniation of the stomach and additional abdominal structures can result in gastric outlet obstruction, gastric volvulus, or intestinal obstruction. […] Hiatal hernias can present with non-gastrointestinal symptoms, obscuring the diagnosis in such patients on initial presentation. As a hiatal hernia enlarges and more stomach or additional abdominal structures move into the mediastinum, respiratory manifestations may predominate. Typical pulmonary symptoms with hiatal hernia include dyspnea and atelectasis as a result of pulmonary compression.

• #29 Atypical and typical manifestations of the hiatal hernia – Goodwin – Annals of Laparoscopic and Endoscopic Surgery

  https://ales.amegroups.org/article/view/6254/html

  The increased prevalence of GERD with hiatal hernias contribute to the association of a hiatal hernia with pulmonary fibrosis. […] Although this symptomatology is not cardiac in nature, hiatal hernias infrequently manifest as cardiac arrhythmias. In a large population-based study, hiatal hernias were associated with an increased prevalence of atrial fibrillation.

• #30 Hiatus Hernia – El Salvador Atlas of Gastrointestinal Video Endoscopy- gastrointestinalatlas.com

  https://www.gastrointestinalatlas.com/english/hiatus_hernia_.html

  Some complications are specific for a hiatal hernia. […] By far, the majority of hiatal hernias are asymptomatic. […] In rare cases, however, a hiatal hernia may be responsible for intermittent bleeding from associated esophagitis, erosions (Cameron ulcers), or a discrete esophageal ulcer, leading to iron-deficiency anemia. […] The prevalence of large hernias in patients with iron deficiency anemia is 6-7%.

• #31 Hiatus Hernia – El Salvador Atlas of Gastrointestinal Video Endoscopy- gastrointestinalatlas.com

  https://www.gastrointestinalatlas.com/english/hiatus_hernia_.html

  A hiatal hernia occurs when a portion of the stomach prolapses through the diaphragmatic esophageal hiatus. […] Although the existence of hiatal hernia has been described in earlier medical literature, it has come under scrutiny only in the last century or so because of its association with gastroesophageal reflux disease (GERD) and its complications. […] By far, most hiatal hernias are asymptomatic and are discovered incidentally. […] On rare occasion, a life-threatening complication, such as gastric volvulus or strangulation, may present acutely. […] The size of the hiatus is not fixed, but narrows whenever intra-abdominal pressure rises, such as when lifting weights or coughing. […] Hiatal hernias are relatively common and, in themselves, do not cause symptoms. For this reason, most people with hiatal hernias are asymptomatic.

• #32 Massive hiatal hernia involving prolapse of the entire stomach and pancreas resulting in pancreatitis and bile duct dilatation: a case report | Surgical Case Reports | Full Text

  https://surgicalcasereports.springeropen.com/articles/10.1186/s40792-020-0773-8

  Hiatal hernia is defined by the permanent or intermittent prolapse of any abdominal structure into the chest through the diaphragmatic esophageal hiatus. […] The etiology can be folding and resultant obstruction of the main pancreatic and extrahepatic biliary ducts to drainage. […] A rare massive hiatal hernia, involving the stomach and pancreatic body and tail, can cause acute pancreatitis with bile duct dilatation. […] The mechanism of pancreatitis due to herniation of the pancreas is presumed to be repeated damage of the pancreas and ischemia as a consequence of intermittent stretching of the blood vessels supplying the pancreas. […] Another conceivable mechanism includes distortion of the pancreas, which impedes the normal pancreatic outflow, thereby leading to intraductal hypertension resulting in inflammation.

• #33 Ascites Worsening Due to a Large Hiatal Hernia Compressing Hepatic Venous Outflow: A Case Report | Stavi | Journal of Medical Cases

  https://www.journalmc.org/index.php/JMC/article/view/1559/1331

  A hiatal hernia causing or aggravating ascites by compressing the hepatic veins has been rarely reported in adults. […] A right-sided heart catheterization demonstrated a significant pressure gradient between the inferior vena cava and the right atrium. […] The outcome indicates that the huge hiatal hernia, by creating hepatic venous outflow obstruction, was the underlying mechanism for ascites aggravation. […] A large ascites without the presence of esophageal varices implied that the mechanism was post sinusoidal obstruction. […] The finding of an external pressure on the right atrium combined with a pressure gradient between the inferior vena cava and the right atrium led to the conclusion that the findings are due to external compression by the huge hiatal hernia. […] The hiatal hernia, most probably, was not the cause for the ascites formation but it was the cause of worsening ascites. […] Portal hypertension caused by external compression of the inferior vena cava was reported in cases of trauma, malignancy or cysts. […] Nevertheless, ascites worsened by a hiatal hernia was never reported in humans according to our best knowledge.

• #34

  https://link.springer.com/article/10.1007/s00464-021-08887-z

  Hiatal hernia recurrence following surgical repair is common. We sought to define the most common anatomic location and mechanism for hiatal failure to inform technical strategies to decrease recurrence rates. […] Mechanism of recurrence was defined as disruption of the previous repair or dilation of the hiatus. […] The mechanism of recurrence was dilation in 74% and disruption in 26%. Disruption as a mechanism was most common in circumferential hiatal failures. […] The most common location and mechanism for hiatal hernia recurrence is anterior dilation of the hiatus. Outcomes following techniques designed to reinforce the anterior hiatus and perhaps to prevent hiatal dilation should be explored.

• #35 Causes of unsuccessful surgical treatment of hiatal hernia – Bechvaya – Pediatrician (St. Petersburg)

  https://journals.eco-vector.com/pediatr/article/view/34604

  The anatomical causes for the recurrence of hiatal hernias after surgical treatment include large esophageal opening of the diaphragm, mechanical weakness of the muscular crura, and secondary or primary shortening of the esophagus. […] The mechanical weakness of the diaphragm crura (e. g., hypotrophy, fibrosis) is also considered the most important factor in grafting failure. […] A decrease in the length of the esophagus (secondary or primary), along with the aforementioned conditions, is considered the most important factor but most difficult to overcome in the recurrence of hiatal hernias. […] Contraction of the cruras of the diaphragm during respiratory excursions is an important physiological factor that increases significantly the load on the plastic zone of the esophageal hiatus.

• #36 Causes of unsuccessful surgical treatment of hiatal hernia – Bechvaya – Pediatrician (St. Petersburg)

  https://journals.eco-vector.com/pediatr/article/view/34604

  Peristaltic contractions of the esophagus, which are an integral component of its physiological function, are also considered a factor that increases the risk of repeated displacement of the stomach into the mediastinum. […] Thus, surgical treatment outcomes of hiatal hernia are affected by diverse causes and factors. Some of them are amenable to elimination or correction, while others do not yet have a final solution and require further experimental and clinical studies.

• #37 Clinical Significance of Hiatal Hernia

  https://www.gutnliver.org/journal/view.html?pn=vol&uid=284&vmd=Full

  The relationship between hiatal hernias and gastroesophageal reflux disease (GERD) has been greatly debated over the past decades, with the importance of hiatal hernias first being overemphasized and then later being nearly neglected. […] It is now understood that both the anatomical (hiatal hernia) and the physiological (lower esophageal sphincter) features of the gastroesophageal junction play important, but independent, roles in the pathogenesis of GERD, constituting the widely accepted „two-sphincter hypothesis.” […] The gastroesophageal junction becomes incompetent and esophageal acid clearance is compromised in patients with hiatal hernia, which facilitates the development of GERD. […] Of the different types of hiatal hernias (types I, II, III, and IV), type I (sliding) hiatal hernias are closely associated with GERD.

• #38 Atypical and typical manifestations of the hiatal hernia – Goodwin – Annals of Laparoscopic and Endoscopic Surgery

  https://ales.amegroups.org/article/view/6254/html

  The true incidence and prevalence of hiatal hernia is difficult to quantify, as many patients remain asymptomatic and undiagnosed from the hernia. Of patients with symptoms, manifestations may be wide-ranging and include reflux, obstruction, pulmonary, and cardiac symptoms. Manifestations may be typical or atypical and comprise a broad differential that can make the diagnosis difficult for the clinician based on history alone. […] The presence of a hiatal hernia is closely related to reflux symptoms and associated complications. Patients with a hiatal hernia are significantly more likely to present with GERD symptoms compared to those without a hiatal hernia. Furthermore, symptomatic GERD patients are more likely to have a hiatal hernia than those without symptoms. GERD symptoms are more common in Type 1 hiatal hernias, and the size of the hernia can impact symptom severity.

• #39 Fundoplication, Hiatal Hernia Repair and Esophageal Dysmotility – Houston Heartburn and Reflux Center

  https://houstonheartburn.com/fundoplication-hiatal-hernia-repair-and-esophageal-dysmotility/

  Let me start by debunking a common myth about hiatal hernias. It is commonly thought that a hiatal hernia causes acid reflux. In reality, acid reflux causes a hiatal hernia to develop. […] Chronic acid reflux causes the esophageal muscles to contract upward away from acid. This upward movement of the esophagus slowly drags the stomach through the hiatal opening. As a result, a hiatal hernia develops and continues to grow in size as long as acid reflux is not stopped. From this perspective, Natalie, a hiatal hernia is a consequence of untreated acid reflux rather than the cause. […] However, the root cause of acid reflux is not just hiatal hernia. Indeed, the etiology of acid reflux is multifactorial and remains poorly understood. […] By the way, as the esophagus retracts into the mediastinum in response to acid reflux, esophageal motility weakens. Most acid reflux patients have esophageal dysmotility. Esophageal dysmotility contributes to acid reflux by preventing effective acid clearance from the esophagus. Hence, both hiatal hernia and esophageal dysmotility are caused by acid reflux and both contribute to acid reflux creating a viscous circle that feeds on itself. For this reason, acid reflux is a chronic and progressive disease. GERD symptoms get worse and hiatal hernia size increases with time.

• #40 Clinical Significance of Hiatal Hernia

  https://www.gutnliver.org/journal/view.html?pn=vol&uid=284&vmd=Full

  These above mentioned associations between hiatal hernia and reflux symptoms, reflux esophagitis, Barrett’s esophagus and esophageal adenocarcinoma are largely due to the disruption of many of the antireflux mechanisms that leads to increased esophageal acid exposure. […] The presence of hiatal hernia per se is not an indication for treatment, and therapy should be given to those with symptoms attributable to this condition.

• #41 Hiatal Hernia – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK562200/

  The management of hiatal hernias depends on the type of hernia and the severity of the symptoms. The initial treatment given to a patient presenting with typical GERD symptoms in an outpatient setting includes a double dose of a proton pump inhibitor (PPI), which can be both therapeutic and diagnostic in that persistent symptoms often require a more extensive evaluation.

• #42 Hiatal Hernia: Causes, Symptoms, Diagnosis & Treatment

  https://www.clevelandclinicabudhabi.ae/en/health-hub/health-resource/diseases-and-conditions/hiatal-hernia

  A hiatal hernia occurs when the upper part of the stomach pushes through an opening in the diaphragm and into the chest cavity. […] The most common cause of a hiatal hernia is an increase in pressure in the abdominal cavity. […] Pressure can come from coughing, vomiting, straining during a bowel movement, heavy lifting, or physical strain. […] Surgery may also be needed in people with a hiatal hernia who also have severe, long-lasting (chronic) esophageal reflux whose symptoms are not relieved by medical treatments. […] The goal of this surgery is to correct gastroesophageal reflux by creating an improved valve mechanism at the bottom of the esophagus. […] Surgery involves pulling the hiatal hernia back into the abdomen and creating an improved valve mechanism at the bottom of the esophagus and closing the hole in the diaphragm muscle. […] A laparoscopic repair of hiatal hernia and reflux, called Nissen Fundoplication, is about 90 percent effective in most patients.

• #43 Hiatal Hernia | EndoUnit

  https://www.endounit.gr/en/pathiseis/diafragmatokili/

  The most common cause of hiatal hernia is increased pressure in the abdominal cavity. […] Increased pressure in the abdomen causes a portion of the stomach to push through the diaphragm into the thoracic cavity. […] Surgery is required if the part of the stomach that enters the thorax is compressed so strongly that blood supply may be cut off. […] The goal of this surgery is to correct gastroesophageal reflux by creating an improved valve mechanism at the bottom of the esophagus. […] The surgery involves pulling the hiatal hernia back into the abdomen and creating an improved valve mechanism at the bottom of the esophagus by closing the opening in the diaphragm muscle.

• #44 Hiatal Hernia Treatment in Appleton, WI | Peter Janu, MD

  https://peterjanumd.com/heartburn-treatment-hiatal-hernia-treatment/

  Hiatal hernia develops in the muscle of the diaphragm. Normally the anatomy allows the passage of the esophagus, which is the muscle tube that connects the mouth to the stomach, through the chest. The passage through the diaphragm is the diaphragmatic hiatus. That muscular passageway contributes to the barrier that prevents the contents of the stomach from going the wrong direction. A hiatal hernia means that the passageway enlarges. The larger or wider the passage becomes, the less it can contribute to the valve barrier at the connection between the esophagus and stomach. Additionally, the larger passageway allows the stomach to slide upwards into the chest, leading to more symptoms including pain, bloating, trouble swallowing, and increased issues of heartburn and reflux. […] The hernia is repaired with stitches to reduce the size of the hole back to its normal size, snug around the esophagus. Depending on the defect, sometimes the repair is reinforced with mesh. To complete the repair, the valve mechanism is also addressed at the time of hernia repair. This is accomplished with a traditional fundoplication approach, Nissen (complete) or Toupet (partial) fundoplication, or alternatively with a magnetic sphincter augmentation implant or even an endoscopic reconstruction approach.

• #45 | General Surgeon & Foregut Surgeon located in Lone Tree, CO | Institute of Esophageal and Reflux Surgery

  https://www.iersurgery.com/content/large-hiatal-hernia-paraesophageal-hernia

  Large or giant hiatal hernias often cause a portion of the stomach to be up in the chest and can result in reflux or other problems including chest pain, food sticking, painful upper abdominal bloating, and the feeling of getting full early or shortness of breath, especially after eating. […] Paraesophageal hernias are one type of large hiatal hernia and occur when the stomach slides up beside the esophagus. […] Symptoms of paraesophageal hernias often include bloating and chest pain. […] When a hiatal hernia leads to deformation of the antireflux barrier, it is repaired by performing a laparoscopic fundoplication. […] Although up to 90% of patients with GERD have a hiatal hernia, the degree of that hiatal hernia is variable, and in many patients the hiatal hernia is fairly minimal (less than 2cm in height). […] Large hiatal hernias/paraesophageal hernias can cause chest pain (especially after eating), shortness of breath, and early satiety (getting full quickly).

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