HIATAL HERNIA (hiatus hernia)

Jarah Mae Amoc

Saint Thea Acaylar
Rogelyn Magtuba

Definition: it is the intermittent protrusion of the stomach up through the esophageal opening in the diaphragm.

When this occurs, the volume of the stomach is suddenly restricted, leading to periodic vomiting similar to
that gastroesophageal reflux. A small hiatal hernia usually doesn't cause problems. You may never know you have
one unless your doctor discovers it when checking for another condition, but a large hiatal hernia can allow food
and acid to back up into your esophagus, leading to heartburn.

INCIDENCE

Hiatal hernias are disproportionally found in older individuals. One study of the general population found
that roughly one in 50 adults in their 60s had a hiatal hernia visible on a computed tomography (CT) scan. This
compares to approximately eight out of every 50 adults in their 80s.

Types of Hernia

There are different types of hernia, each of which is related to a different abnormality in the body.

Sliding Hernia

A sliding hernia is a condition in which your stomach can periodically slide above the diaphragm due to a wide
opening in the diaphragm or weakness of the diaphragmatic muscle.

If you have a sliding hernia, your stomach is not anchored in place, but the anatomical relationship between your
stomach and your esophagus, which lies right above it, is maintained as a normal anatomical relationship.

The hernia worsens during times of abdominal pressure, with the stomach literally sliding into the space above the
diaphragm. The stomach can then return to its original position when there is no excessive abdominal pressure.

With a sliding hiatal hernia, the symptoms can come and go based on where the stomach is at any moment.

Paraesophageal Hernia

A paraesophageal hernia is a type of hiatal hernia caused when the stomach is forced upward through an
enlarged opening in the diaphragm. Symptoms of a paraesophageal hernia tend to be chronic (persistent).

Unlike a sliding hernia, a paraesophageal hernia does not move or slide around. Rather, it remains in an abnormal
position next to the esophagus where it can become incarcerated (trapped) in the diaphragm. This can lead
to ischemia (the cutting off of the blood supply), a medical emergency requiring immediate surgery.
PATHOPHYSIOLOGY

A hiatal hernia occurs when the upper part of the stomach pushes through an opening in the diaphragm
and into the chest cavity. The diaphragm is the thin muscle wall that separates the chest cavity from the abdomen.
The opening in the diaphragm is where the esophagus and stomach join. A hiatal hernia occurs when part of the
stomach protrudes up into the chest through the sheet of muscle called the diaphragm. This may result from a
weakening of the surrounding tissues and may be aggravated by obesity and/or smoking

Causes

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 an unusually large hiatus
 Persistent and intense pressure on the surrounding muscles, such as while coughing, vomiting, straining
during a bowel movement, exercising or lifting heavy objects

SIGNS AND SYMPTOMS

Most small hiatal hernias cause no signs or symptoms. But larger hiatal hernias can cause:

 Heartburn
 Regurgitation of food or liquids into the mouth
 Backflow of stomach acid into the esophagus (acid reflux)
 Difficulty swallowing
 Chest or abdominal pain
 Feeling full soon after you eat
 Shortness of breath
 Vomiting of blood or passing of black stools, which may indicate gastrointestinal bleeding

Risk factors

There are a few lifestyle risk factors that increase your chances of having a hiatal hernia. For many of
these risk factors, the link to hiatal hernia is well established, but the cause remains unclear.
Obesity: Obesity is one of the biggest risk factors for hiatal hernia. This may be due to increased pressure on the
diaphragm due to heavy weight.

Heavy lifting: It is believed that heavy lifting puts stress on the diaphragmatic muscle, increasing the chances of an
enlarged hole that allows the stomach to protrude above the diaphragm.

Coughing: The abdominal pressure caused by coughing can allow or cause the stomach to squeeze through the
diaphragm.

Straining: Straining may increase the chances of having a hiatal hernia due to excess pressure on the diaphragm.
This includes straining for a bowel movement. 

Pregnancy: The abdominal pressure and hormonal changes of pregnancy can increase the chances of a hiatal
hernia.

Smoking: Smoking weakens the muscles of the diaphragm, allowing the stomach to protrude above the
diaphragm.

COMPLICATIONS

It's rare for a hiatus hernia to cause complications, but long-term damage to the esophagus caused by
leaking stomach acid can lead to:

 Ulcers
 scarring and changes to the cells of the esophagus, which can increase your risk of esophageal
cancer.
Repeated reflux of acidic content may result in:
 Coughing spasms
 Asthma
 Pneumonia
 Bronchitis

DIAGNOSTIC TESTING

Common tests & procedures

Complete blood count (CBC): To check for anemia due to blood loss.

pH test: To measure the pH or amount of acid that flows into the esophagus from the stomach during a 24-hour
period.

Endoscopy: To check for inflammation in the digestive tract.

Manometry: To measure the pressure and movement inside the esophagus.

Barium swallow: A type of X-ray that provides clear silhouette of stomach, esophagus, and duodenum image.

NURSING DIAGNOSIS

1. Acute Pain

Related Factors:
 Chemical burn of gastric mucosa or oral cavity
 Physical response, such as reflex muscle spasm in stomach wall

Evidenced by:

 Verbalization of pain
 Abdominal guarding
 Rigid body posture
 Facial grimacing
 Autonomic responses, such as changes in vital signs in reaction to acute pain

Desired outcomes:

 The client will verbalize relief of pain

 The client will demonstrate a relaxed body posture and be able to sleep or rest appropriately

Nursing Interventions:

 Assess reports of pain, including location, duration and intensity

 Note nonverbal pain cues such as restlessness, reluctance to move, abdominal guarding, tachycardia and
diaphoresis
 Identify factors that aggravate or alleviate the pain

2. Risk for Imbalanced Nutrition

Risk factors:

 Vomiting
 Insufficient meal/ food intake

Evidenced by:

 Reduced weight

Desired outcomes

 The patient consumes adequate nutrition

 The patient maintains the desired/ appropriate weight
 The client should not feel nauseous and there is no vomiting involved

Nursing interventions:

 Complete thorough nutrition screening

 Provide nutritional supplements as appropriate or ordered
 Educate the baby’s mother about the body’s nutritional needs

NURSNG INTERVENTIONS

A baby can be kept in an upright position to help prevent the condition from recurring. Medication reduce
acid secretions may be helpful. If the condition has not corrected itself by the time the infant is 6 months old even
with maintaining an upright position most of the day. Other interventions include:

1.Monitor respiratory rate, depth, and effort.

2.Note any signs of aspiration such as dyspnea, cough, cyanosis, wheezing, or fever.

3.Auscultate for lung sounds Assess patient's ability to swallow and the presence of gag reflex. 4.Avoid placing
patient in supine position, have the patient sit upright after meals.

5.Instruct the patient to chew food thoroughly and eat slowly.

6.Assist/instruct in relaxation techniques deep/slow breathing

MEDICAL MGT

Laparoscopic surgery may be performed to reduce the ability of the stomach to protrude through the
diaphragm

Antacids: Neutralize the stomach acids.

H-2 receptor blockers: Histamine 2 receptor antagonist reduces the acid production.

If you experience heartburn and acid reflux, your doctor may recommend:

 Antacids that neutralize stomach acid. Antacids, such as Mylanta, Rolaids and Tums, may provide quick
relief. Overuse of some antacids can cause side effects, such as diarrhea or sometimes kidney problems.
 Medications to reduce acid production. These medications — known as H-2-receptor blockers — include
cimetidine (Tagamet HB), famotidine (Pepcid AC) and nizatidine (Axid AR). Stronger versions are available
by prescription.
 Medications that block acid production and heal the esophagus. These medications — known as proton
pump inhibitors — are stronger acid blockers than H-2-receptor blockers and allow time for damaged
esophageal tissue to heal. Over-the-counter proton pump inhibitors include lansoprazole (Prevacid 24HR)
and omeprazole (Prilosec, Zegerid). Stronger versions are available in prescription form.
 Surgery- Sometimes a hiatal hernia requires surgery. Surgery is generally used for people who aren't
helped by medications to relieve heartburn and acid reflux, or have complications such as severe
inflammation or narrowing of the esophagus. Surgery to repair a hiatal hernia may involve pulling your
stomach down into your abdomen and making the opening in your diaphragm smaller or reconstructing
an esophageal sphincter. In some cases, hiatal hernia surgery is combined with weight-loss surgery, such as
a sleeve gastrectomy. Surgery may be performed using a single incision in your chest wall (thoracotomy) or
using a minimally invasive technique called laparoscopy. In laparoscopic surgery, your surgeon inserts a
tiny camera and special surgical tools through several small incisions in your abdomen. The operation is
then performed while your surgeon views images from inside your body that are displayed on a video
monitor.

PROCEDURES

Laparoscopy: Inserting surgical instruments in abdomen through small incisions and wrapping the upper region of
the stomach.

Thoracotomy:

Sleeve Gastrectomy:
Nutrition

Foods to eat:

 Avoid foods that trigger Heartburn, such as chocolate, onions, spicy foods, citrus fruits and tomato-based
foods
 Avoid alcohol
 Eat at least two to three hours before bedtime