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2017

Pathophysiology of Hiatal HerniaCourtney Adamscourtney.adams@otterbein.edu

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Recommended CitationAdams, Courtney, "Pathophysiology of Hiatal Hernia" (2017). Master of Science in Nursing (MSN) Student Scholarship. 252.https://digitalcommons.otterbein.edu/stu_msn/252

Courtney M. Adams RN, BSN, CCRNOtterbeinUniversity,Westerville,Ohio

• Iwasdiagnosedwithahiatalherniafromacaraccidentcausinganeverydaysymptomofgastroesophagealrefluxdisease(GERD).

• IworkinacancerhospitalwheremanyindividualssufferfromGERDandinturnsomeresultinEsophagealCancer.

• Hiatalhernia(HH)isacommondisorderaffecting10-50%ofthepopulation(Berselli etal.,2015).

• HHischaracterizedbytheupperpartofthestomachthatpushesthroughawideningofthediaphragmatichiatusintothechestcavity(Berselli etal.,2015).

• Normallytheesophagusgoesthroughanopeningcalledthehiatusatthediaphragmtothestomach(ClevelandClinic,2015).

(ClevelandClinic,2015).

• TypeIisthemostcommonamongadultscalledaslidingHH,whichconsistsofthegastroesophagealjunctionmigratingabovethediaphragmwhilethestomachremainsinposition.

• TypeIIiscalledapurepara-esophagealhernia,wherethefunduscomesthroughthediaphragmintothechestcavitywhilethegastroesophagealjunctionstaysintheabdominalcavity.

• TypeIIIcombinestypeIandIIwithboththefundusandgastroesophagealjunctioncomeintothechestcavity.

• TypeIVisoftencalledagiantherniabecauseotherstructuresintheabdomenbesidethestomachcanherniateintothechestcavity.

• (Berselli etal.,2015)

• Increasedpressurefromtheabdominalcavitycancausetheherniationofcontentsfromtheabdomentobepushedintothechestcavity.Someofthecausesofherniationare:

• OverweightorPregnancy• PrevalenceofHHincreaseswithageandbodymassindex(BMI)(Roman&Kahrilas,2014).

• Vomiting,heavylifting,physicalstrain,orstrainingforabowelmovement(ClevelandClinic,2015).

• Ariseinabdominalpressureandadecreaseinthoracicpressure,suchasobesityandchroniclungdisease(Menezes&Herbella,2017).

• Causedbyinjurytothearea,whichiswhathappenedtomeinmycaraccident.

• Congenitally(ClevelandClinic,2015)

• GERDbeingthemainsymptomofHHrequiresustoknowthepathophysiologyofGERDtoknowhowtomanageaHH.

• TheloweresophagealsphinctermaycauseGERDbythemusclelosingitstoneortheresultofahiatalhernia.Whenthesphincterallowsforgastricacidtorefluxupintotheesophagus,itmayerodetheliningoftheesophagus(Nwokediuko,2012).

• Normallyyouhaverefluxwhentheloweresophagealsphincter(LES)relaxes.ThenormalbasalpressureoftheLESis10-45mmhg(Nwokediuko,2012).Patientsareatriskwithpressuresof6mmhgorless(Tatarian,Pucci &Palazzo,2016).

• Chronicesophagealrefluxmaycauseesophagitis,Barrett’sesophagus,andesophagealadenocarcinoma(Nwokediuko,2012).

(Federle,2015).

• TypeIisthemostcommonamongadultscalledaslidingHH,whichconsistsofthegastroesophagealjunctionmigratingabovethediaphragmwhilethestomachremainsinposition.

• TypeIIiscalledapurepara-esophagealhernia,wherethefunduscomesthroughthediaphragmintothechestcavitywhilethegastroesophagealjunctionstaysintheabdominalcavity.

• TypeIIIcombinestypeIandIIwithboththefundusandgastroesophagealjunctioncomeintothechestcavity.

• TypeIVisoftencalledagiantherniabecauseotherstructuresintheabdomenbesidethestomachcanherniateintothechestcavity.

• (Berselli etal.,2015)

Akst,L.M.,Haque,O.J.,Clarke,J.O.,Hillel,A.T.,Best,S.R.A,andAltman,K.W.(2017).Thechangingimpactofgastroesophagealrefluxdiseaseinclinicalpractice:Anupdatedstudy.AnnalsofOtology,Rhinology,&Laryngology,126(3),229-235.doi:10.1177/0003489416686586Banki,F.,Kaushik,C.,Rolfe,D.,Chawla,M.,Casimir,R.,&MillerIII,C.C.(2016).Laparoscopicreoperative antireflux surgery:Asafeprocedurewithhighpatientsatisfactionandlowmorbidity.AmericanJournalofSurgery,212(6),doi:10.1016/j.amjsurg.2016.09.011Berselli,M.,Livraghi,L.,Latham,L.,Farassino,L.,RotaBacchetta,G.L.,Pasqua,N.,&Cocozza,E.(2015).Laparoscopicrepairofvoluminoussymptomatichiatalherniausingabsorbablesyntheticmesh.MinimallyInvasiveTherapy&AlliedTechnologies,24(6),372-376.doi:10.3109/13645706.2015.1064446ClevelandClinic.(2015).Hiatalhernia.Retrievedfromhttps://my.clevelandclinic.org/health/articles/hiatal-herniaFederle,M.P.(2015).Hiatalhernia.ClinicalGate.Retrievedfromhttps://clinicalgate.com/hiatal-hernia-2/Khajanchee,Y.S.,Cassera,M.A.,Swanstrom,L.L.,&Dunst,C.M.(2013).Diagnosisoftype1hiatalhernia:Acomparisonofhigh-resolutionmanometryandendoscopy.DiseaseofEsophagus,25(1)1-6.doi:10.1111/j.1442-2050.2011.01314Menezes,M.A.&Herbella,F.A.M.(2017).Pathophysiologyofgastroesophagealrefluxdisease.WorldJournalofSurgery,41(7),1666-1671.doi:10.1007/s00268-017-3952-4Nwokediuko,S.C.(2012).Currenttrendsinthemanagementofgastroesophagealrefluxdisease:Areview.ISRNGastroenterology,2012.doi:10.5402/2012/391631Roman,S.&Kahrilas,P.(2014)Thediagnosisandmanagementofhiatushernia.TheBMJ,349.doi:https://doi.org/10.1136/bmj.g6154Singh,M.,Lee,J.,Gupta,N.,Gaddam,S.,Smith,B.K.,Wani,S.B.,Sullivan,D.K.,Rastogi,A.,Bansal,A.,Donnelly,J.E.,&Sharma,P.(2013).Weightlosscanleadtoresolutionofgastroesophagealrefluxdiseasesymptoms:aprospectiveinterventiontrial.Obesity,21(2),284-290.doi:10.1002/oby.20279Tatarian,T.,Pucci,M.J.,&Palazzo,F.(2016).Amodernapproachtothesurgicaltreatmentofgastroesophagealrefluxdisease.JournalofLaparoendoscopic &AdvancedSurgicalTechniques,26(3),174-179.doi:10.1089/lap.2015.0530Weijenborg,P.W.,VanHoeij,F.B.,Smout,A.J.,&Bredenoord,A.J.(2015).Accuracyofhiatalherniadetectionwithesophagealhighresolutionmanometry.Neurogastroenterology &Motility,27(2),293-299.doi:10.1111/nmo.12507

BeingdiagnosedwithHHhascausedmetogrowintheunderstandingofthiscondition,andnotonlyhelpbettereducatemyself,butalsobeabletobetterassistthosethatIencounterthatmayalsosufferfromasimilardiagnosis.

• Patientsarediagnosedbyendoscopy,bariumswallow,esophagealmanometryandhigh-resolutionmanometry(HRM)postGERDsymptoms.ManystudiesarefavoringHRMwithrulingoutthediagnosisofHH(Khajanchee,Cassera,Swanstrom,&Dunst,2013).

• HRMishighlysensitiveandspecificforhiatalherniadetection,exceedingthesensitivityofendoscopyorradiographyalone.HRMsensitivitywas92%andthespecificityof95%(Weijenborg,VanHoeij,Smout,&Bredenoord,2015).

• Educationiskey!ManagementofHHisverysimilartoGERDmanagement.Somethingsnursescanteachtheirpatientsare:

• Avoidingcertainfoodssuchascoffee,alcohol,chocolate,fattyandacidicmeals(Nwokediuko,2012).

• Eatmealsatleast3-4hrsbeforelyingdown• Keepingtheheadofbedhigherthan6inches• Avoidtightclothingthatcancauseincreasedpressurein

theabdomenarea• Losingweight• (ClevelandClinic,2015)

• SymptomaticHHshouldberepairedbyalaparoscopicapproach(Berselli etal.,2015).

• Itiscontroversialwhethertohaveanopenprocedureorlaparoscopicapproach,astudyshowedtheuseofanabsorbablesyntheticmeshwithalaparoscopicapproachisrelatedtolowreoccurrencerates(Berselli etal.,2015).

• Lowmorbidityandincreasedpatientsatisfactionisrelatedtothelaparoscopicapproachwhencomparedtoanopenapproach(Bankietal.,2016).

• Beforesurgeryisconsidereddoctorslookatwhetherthepatienthasfailedmedicalmanagement(Tatarianetal.,2016).Medicationsincludeantacids,protonpumpinhibitors(PPI),andhistamine2receptorantagonists(H2RA)(Nwokediuko,2012).

• Onestudyshowedthatasobesityratesrise,thepresenceofGERDwillalsorise(Akst etal.,2017).ThosewhoareobesearetwoandhalftimesmorelikelytohaveGERDsymptomsthanthosewhoarenotobese(Nwokediuko,2012).Forthosewhoareoverweightorobese,weightlossalonemayreducesymptomsofGERDcompletely(Singhetal.,2013).