What is a stomach hernia?
A stomach hernia is the protrusion of the upper part of the stomach through the diaphragmatic opening. This means that a portion of the stomach is abnormally protruding into the thoracic (chest) cavity. The proper medical term for a stomach hernia is a hiatal hernia or hiatus hernia. Although most cases are mild and largely asymptomatic (no symptoms present), in severe cases a stomach hernia can cause considerable discomfort and pain and lead to regurgitation. The rise of the acidic stomach acid contents into the esophagus (food pipe) has a host of other complications within the esophagus, throat and mouth.
Reasons for a Stomach Hernia
Normally the stomach sits completely in the abdominal cavity, immediately under the diaphrgam. The esophagus (food pipe) runs from the throat, through the thoracic cavity and passes into the abdominal cavity through an opening in the diaphragm (esophageal hiatus). The esophagus then immediately joins with the stomach (gastroesophageal junction), thereby passing any food that is swallowed into the stomach. A valve known as the LES (lower esophageal sphincter) opens to allow food into the stomach and closes immediately afterwards to prevent the stomach contents from rising up into the esophagus.
The human diaphragm is flat sheet of muscle that is mainly responsible for respiration (breathing). It also serves to separate the thoracic (chest) and abdominal cavities. It has several large and small openings that allow for important structures like the esophagus, blood vessels and nerves to travel between the abdominal and thoracic cavities. The esophageal hiatus, which is the opening through which the esophagus passes, is usually small and apart from some nerves and lymphatic vessels that also pass through this opening, there is usually no space for any other structures. The stomach being such a large organ is therefore unable to pass through it.
The different openings in the diaphragm are reinforced with muscle fibers that ensure that these ‘holes’ do not become stretched and larger over time. Therefore no organs from the abdominal cavity and enter the thoracic cavity and vice versa. However, under certain circumstances a person may be born with a larger than normal opening or some event may cause the ‘hole’ to stretch slightly. Even a minor increase in the size of the opening may be sufficient for protrusions like a stomach hernia to occur.
Causes of a stomach hernia
- Age-related muscle weakness and loss of elasticity of tissue throughout the body can weaken the reinforcing around the diaphragmatic openings thereby allowing it to stretch and widen over time. This is the reason why stomach hernias are more common in older people, particularly after the age of 50 years.
- Increased intra-abdominal pressure (raised pressure within the abdomen) may force the stomach through the diaphragmatic opening and cause it to widen over time. This may be associated with :
- Ascites (fluid accumulation in the abdomen)
- Repeated straining to have a bowel movement as is seen with constipation.
- Congenital defect where the diaphragmatic opening is larger than normal.
- Shortening of the esophagus which may occur with recurrent inflammation of the esophagus (esophagitis).
Types of stomach hernias
There are three different types of stomach hernias :
- Sliding hiatal hernia (type 1)
- Rolling hiatal hernia (type 2)
- Mixed hiatal hernia (type 3)
Diagram A indicates a normal stomach. B illustrates the early stages of sliding hernia. C is a typical sliding hernia. D is a paraesophageal hernia.
The area where the esophagus meets the stomach is known as the gastroesophageal junction. This is also the location of the lower esophageal sphincter (LES). A sliding hernia is when this part of the esophagus is pulled upwards into the thoracic cavity sometimes pulling a portion of the stomach with it. The difference in pressure within this thoracic cavity may also lead to dysfunction of the LES. Most stomach hernias, almost 95%, are sliding types.
This is a rarely seen type of hernia. Here the gastroesophageal junction stays in its normal position but a defect in the diaphragmatic opening allows the upper portion of the stomach known as the fundus to protrude into the thoracic cavity. Less frequently a portion of the colon or even the spleen can protrude through the opening. It is also known as a rolling hiatal hernia because the fundus of the stomach rolls in an out of the thoracic cavity.
This is a combination of a sliding and paraesophageal hernia. The gastroesophageal junction moves up into the thoracic cavity and the fundus of the stomach rolls in an out of the thoracic cavity.
Stomach hernia symptoms
Most stomach hernias are asymptomatic especially small hernias. It may remain asymptomatic for months to years or even throughout life. The severity of the symptoms increases with the size of the hernia. These symptoms include :
- Excessive belching
- Upper abdominal pain
- Difficulty swallowing
- Appetite changes
Stomach hernia pain
Pain due to a stomach hernia may extend from the chest to the upper left abdominal quadrant. It is largely due to the acid reflux which leads to burning chest pain (heartburn). Torsion (twisting) and distention (stretching) of the herniated portion may also cause upper abdominal pain on the left side. The pain is most likely to worsen after eating and intensifies with large meals and carbonated beverages.
Stomach hernia vomiting
Reflux and regurgitation of the stomach contents may sometimes be mistaken for vomiting. Regurgitation is passive expulsion of the stomach contents compared to the more forceful vomiting process. It is common in more severe cases of a stomach hernia. Vomiting may also occur when the nausea is intense and after large meals. Vomiting can also exacerbate the hernia further as the increased intra-abdominal pressure may push the stomach further into the thoracic cavity.
Stomach hernia diagnosis
There are a number of upper gastrointestinal conditions that may have a similar presentation to a stomach hernia. Diagnostic investigation is therefore essential to confirm the presence of the hernia. These investigations include :
- X-ray with radiocontrast dye (barium x-ray).
- Upper GI endoscopy
Stomach hernia treatment
The treatment of a stomach hernia depends on the severity of the condition.
- Asymptomatic hernias require no treatment.
- Mild to moderate symptomatic hernias may be controlled with lifestyle changes and medication.
- Severe hernias may require surgery.
The diet and lifestyle changes for a stomach hernia are the same as those outlined in the acid reflux diet. Similarly the medication used for treating a stomach hernia is the same as for other gastroesophageal conditions. This is discussed in detail under stomach acid medication.
Surgery and videos
Surgical procedures to treat a stomach hernia are reserved for severe cases that are unresponsive to lifestyle changes and medication. It is also indicated for cases where there are complications of the stomach hernia and in particular the acid reflux associated with it. These surgical procedures include Nissen fundoplication and laparoscopic paraesophageal hernia repair.
Nissen fundoplication where a portion of the upper stomach (fundus) is wrapped around the lower end of the esophagus. It is the procedure of choice in most stomach hernia cases and can be done as a laparoscopic procedure. This procedure is also used for gastroesophageal reflux disease (GERD).
Laparoscopic paraesophageal hernia repair is done by the means of a synthetic mesh to secure the area after removing the hernia sac from the thoracic cavity.