Hernia hiatal also call hernia of hiatus or hernia of the hiatus is an acquired condition that constitutes one of more the frequently made endoscopic diagnoses, although on diagnosis he is not infrequent. One appears generally in asintomática form or with inespecíficos symptoms and when it makes manifestations clinical, these they are mainly: sournesses, belches, pirosis, ebb tide and regurgitation, known like Disease by Reflujo Gastroesofágico (ERGE).

Secondary complications or to the acid ebb tide or the imprisonment of the stomach in the thorax can be presented/displayed, that can get to jeopardize the life of the patient. The medical handling constitutes the first option of treatment, basically directed to the handling of the manifestations of ERGE, discarding the presence of Helicobacter pylori, same bacterium that is associated to the presence of sintomatología of ERGE. The surgical treatment reserve for those cases that do not respond to the medical handling, presence of complications, great hernias hiatales and hernias paraesofágicas.

Definition and classification

The prolapse of the proximal stomach is defined as hernia hiatal towards the thorax through the esofágico hiatus of the diaphragm. Hernia hiatal is a condition essentially acquired that is not only most frequent of hernias diafragmáticas, but one of the abnormalitys more frequent than affects tracto gastrointestinal (TGI) superior.

Classically hernia hiatal has been classified in three types: Hiatal type I or hernia by sliding (axial) where appears superior displacement of the esophagus-gastric union towards the later mediastino. Is denominated hernia "by sliding" since it has a coat of partial parietal peritoneo, whose later wall is formed by the stomach? Paraesofágica type II or hernia characterized by superior displacement of the bottom gastric, previous and lateral to the esophagus, with the located esophagus-gastric union in its normal intraabdominal position? Mixed type III or where there is superior displacement as much of the union esophagus - gastric like of the gastric bottom. The 85-90% of hernias hiatales is of type I, whereas hernias paraesofágicas pure is found very infrequently.

Epidemiología

The hiatal incidence of hernia is considered in 5 per 1000 in the general population, although a true incidence is difficult to determine because a great number of patients is asintomáticos. The exact prevalence is not known, which obeys to the diversity of criteria, mainly radiological, for the hiatal definition of hernia. The age of more frequent presentation is between 4ª to 6ª decade of the life and difference as far as sex does not exist, although hernias paraesofágicas is more frequent in women. Hernia hiatal has been described more frequently in western countries.

Anatomy The esofágico hiatus of the diaphragm is located to the left of the mean line to level of the tenth torácica vertebra; it is a musculotendinoso ring made up of fibers of the pillars straight and left by the diaphragm, that the previous face and intervertebrales discs of the four first lumbar vertebrae come from, they surround the aorta and the esophagus and they are inserted in the tendinoso center of the diaphragm. Although anatomical variations exist, has been that in more of 80% of the cases, the esofágico hiatus forms mainly of fibers of the right pillar of the diaphragm.

The esophagus happens through the esofágico hiatus from the later mediastino towards the abdomen; in its more inferior portion (1 to 3 cm) is intraabdominal and at this level it is covered by two different layers: the visceral peritoneo and the frenoesofágica membrane. The frenoesofágica membrane or fascia of Laimer, is an elastic, deep conectivo weave layer to the peritoneo, that extends from the crura to the wall of the esophagus, as much superficially as below the diaphragm, and is important in the maintenance of the inferior esofágico sphincter (EEI) within the abdomen.

Etiología

Normally during the swallowing a esofágico shortening due to the contraction of longitudinal muscular fibers takes place, with which the esofagogástrica union (UEG) is displaced in cephalic sense one or more centimeters over the diafragmático hiatus, but by the intrinsic elasticity of the frenoesofágica membrane, the UEG returns to their normal position below the diaphragm when completing the swallowing. A balance between the forces that push the esophagus through the esofágico hiatus and the structures of support exists then that try to maintain the UEG in their normal anatomical position.

By the repetitive process and the progressive degeneration that can happen with the age, in addition to another series of associated factors, the elasticity of the frenoesofágica membrane can diminish and like consequence, the dynamic balance between the swallowing and the herniación can be committed, taking to the superior displacement of the UEG as a result of the greater intraabdominal pressure.

Those conditions that produce a repetitive increase or sharp of the intraabdominal pressure, such as ascitis, obesity and pregnancy, can contribute in the hiatal formation of hernia. Hernia hiatal has been described more frequently in western countries where they have implied like possible factors the low diet in fiber, that entails to greater intraabdominal pressure during the deposition, and to high fat diet that produces retardation in the evacuating with later gastric distension. Hernias paraesofágicas appears when a defect or weakness located in the frenoesofágica membrane and the esofágico hiatus previous and lateral to the esophagus exists.

Clinical presentation

Most of the patients with hernia hiatal by sliding they are asintomáticos. When they become manifest, the sintomatología is given basically by sournesses, belches, pirosis, regurgitation and retroesternal pain, classic symptoms of the ERGE that is the most significant manifestation in the patients with hernia hiatal. Disfagia generally associate to esofagítis, peptic estenosis, ring of Schatzki or by the compression of the diafragmática crura in the herniada portion of the stomach can appear.

The torácico pain in the patients with hernia hiatal can be explained by the association with ERGE, although other mechanisms, as tear or separation of the diafragmática crura by the herniado stomach, or some degree of isquemia of the herniado segment, can contribute to the presence of the pain. Hernias paraesofágicas in general is asintomáticas, when they even reach great sizes. Great herniaciones can produce retroesternal or disnea pain by diminution of the respiratory reserve. Disfagia secondary to the esofágica compression by hernia or to the rotation of the UEG within the herniario coat can be presented/displayed. Symptoms of ERGE also appear in a high percentage of patients with hernia paraesofágica.

Associate manifestations and complications

Gastroesofágico ebb tide the paper of hernia hiatal in the patogénesis of the ERGE has been reason for controversy during many years. Although hernia hiatal contributes clearly to the ERGE in many patients, is difficult to quantify its precise contribution; in addition it is evident that not always hernia hiatal is associate to ERGE and vice versa. The hiatal prevalence of hernia in patients with endoscópica and radiográfica evidence of ERGE varies between 63% to 94%, while the prevalence is smaller in the population control. In a endoscópico study of 670 patients, 63% of the patients with esofagítis had hernia hiatal compared just by 8% of the patients without esofagítis. In patients with documented ERGE, has been in addition a direct relation between the size to hernia hiatal and the degree of disfunción of the EEI, the duration of the episodes of ebb tide, the acid explanation and therefore with the severity of esofagítis.

Physiological studies have demonstrated that the competition of the UEG depends mainly on the characteristics of the EEI (pressure, exposed length to intraabdominal positive pressure and length overall) and of the function like extrinsic sphincter of the diafragmática crura. A deficiency in anyone of these characteristics of the EEI, is associate with incompetencia of the UEG, independent of the hiatal presence or not of hernia. With the superior displacement of the UEG in hernias by sliding, the EEI and the distal esophagus let be put under the intraabdominal positive pressure, staying as only mechanism antiebb tide the intrinsic pressure of the EEI, which frequently is diminished, which ready to the acid ebb tide.

The function as sphincter of the diaphragm is given mainly during the inspiration and situations of dynamic stress, like during the swallowing and in sudden increases of the intraabdominal pressure (cough), of such form that the related episodes of ebb tide to increase of the intraabdominal pressure are more probable that they happen in patients with hernia hiatal. Additionally, in the patients with hernia hiatal, there is commitment of the esofágico evacuating, which slows down the acid explanation after an episode of ebb tide. Hiatal the diafragmática crura in the presence of one hernia is exerting its pressure around the gastric bottom, reason why a atrapamiento of acid in hernia takes place hiatal that flows back towards the esophagus with each episode of swallowing when the EEI relaxes; these events along with an alteration of the esofágica motilidad in patients with ERGE, increases the time of contact with acid of the distal esophagus, increasing the probability of developing sequels by the prolonged exhibition to acid.

Bled Bled hidden or moderate it can be until in a third of the patients with hernia hiatal by symptomatic sliding, being little frequent the massive bled one. Within the possible factors they are the presence of esofagítis, mucous tears Mallory-Weiss type, increase of the ulcerogénico potential of AINES when slowing down itself its explanation and increasing the time of contact with the mucosa. Cameron describes the presence of linear erosions in the gastric body secondary to the chronic mechanical irritation due to the contraction of the diafragmática crura during the respiratory movements, that can produce bled weighs chronic that takes to pictures of iron deficiency. Vólvulos Vólvulus gastric can be organoaxial when the stomach broken throughout its axial longitudinal axis or mesentérico when broken on the axis that unites the smaller curvature with the greater one.

The laxitud or absence of the ligaments of gastric fixation is the primary cause of vólvulus gastric. When being increased the rotation of the stomach takes place commitment of the sanguineous flow and the venous return of the herniado stomach, taking to necrosis, perforation, sepsis and even the death. Herniación of other intraabdominal organs can be presented/displayed towards the torácica cavity in the presence of great hernias hiatales, specially the colon, thin intestine and epiplón. Esofágico shortening the esofágico shortening thinks that it happens as a result of a chronic ERGE to healing and fibrosis that takes to the shortening of the tubular esophagus.

This shortening is identified like one hernia radiologicamente hiatal by sliding that does not reduce in the standing position or that measures more than 5 cm. between the diafragmática crura and the UEG. Benign polipoideas injuries of inflammatory characteristics at level of the union can appear to escamocolumnar. The ring of Schatzki or ring B consists of folds mucous in the distal esophagus, within 3 proximal mm to the union to escamocolumnar, that always is associate with hernia hiatal and constitutes a cause of disfagia in these patients.

STUDIES DIAGNOSES

Radiology

In the thorax x-ray a dependent mass of soft weaves in the later mediastino can be demonstrated, with hidroaéreo level in the great case of hernias. The studies with baritados means of resistance are more exact if it is managed to define the relation of the esofágico hiatus of the diaphragm with the UEG. The presence of a indentación over the diaphragm, which usually considers like the site of transition between the gastric cardia and the esofágico lobby, implies the hiatal existence of one hernia. Another radiográfico finding includes the presence of you fold On guard gastric supradiafragmática.

Esofagograma also is useful to diagnose the esofágico shortening as it were already mentioned. In the case of hernias paraesofágicas, the studies with resistance means show the portion of the gastric bottom located over the diaphragm with the UEG located On guard normal to level of the diaphragm; additionally the presence of volvulus can be demonstrated gastric. The exactitude of these studies in the diagnosis of hernias paraesofágicas is greater than for hernias by sliding, since these last ones can reduce spontaneously.

Endoscopy

Normally the union of the mucosa to escamocolumnar (line Z), that corresponds approximately to the location of the UEG, is to less than 2 cm. over the diafragmático hiatus, of such form that a greater distance between these structures is consistent with the hiatal presence of one hernia. The position of the diafragmático hiatus can become more evident during a deep inspiration.

In the gastric body and with endoscopy in retroflexión, a patuloso, ample diafragmático hiatus can be observed, through as you fold them gastric ascend towards hernia hiatal. Hernias paraesofágicas is appraised better with endoscopio in retroflexión, where the gastric bottom is seen herniando itself throughout the esophagus, while the UEG stays normal On guard. Other studies like the manometría and pHmetría, are not useful for the hiatal diagnosis of hernia, but they are of utility in the study of the ERGE associate. The manometría is fundamental to determine the location, size and pressure of the EEI, like also discarding upheavals of previous the esofágica motilidad to the surgical treatment.

The taking of biopsies always is desirable during one endoscopía to discard the presence of Helicobacter pylori, as well as of organizations like the Esophagus of Barret, that is a premalignant organization, like the cancer in if same.

TREATMENT
Medical treatment

The symptoms associated to hernia hiatal that they are susceptible of medical handling are those having to ERGE. The main therapeutic modalities include modification in the life style, supresoras drug use of the acid secretion and prokinetic agents. In case it exists Helicobacter pylori exists an eradication treatment that works until in a 75% of the cases. And if with this I even complete treatment persists the sintomatología will be necessary that the person lowers of weight, and subjects to an almost free diet of irritating; as well as to follow with a support treatment. Since the symptomatic relapse is frequent later to the suspension of the medical treatment, which forces to treatment of maintenance by long periods of time, the age, the acceptance of the patient to prolonged treatments and the appearance of complications must be had in consideration when continuous medical treatment with definitive surgical treatment is compared.

Surgical treatment

The surgical handling of hernia hiatal symptomatic has several indications, by direct manifestations of hernia hiatal, like: Jailed hiatal Hernia with disfagia. Torácico pain associated to hernia hiatal giant. Patients with severe deficiency of secondary iron to the erosions or ulceraciones in hernia hiatal. Paraesofágica Hernia. Rebellious Sintomatología to the medical treatment. Several surgical options of total or partial funduplicatura exist, that they can be made by transabdominal route (funduplicatura of Nissen, Hill, Toupet) or transtorácica (funduplicatura of Nissen or Belsey - Mark IV) or in open form or by minimumly invasive surgery, but that in general such fulfills principles surgical that are: Reduction of hernia hiatal. Closing of the esofágico hiatus. To restore the function of the EEI.

To replace the intraabdominal esophagus To create a valve mechanism antiebb tide. In those cases of esofágico shortening one is due to make gastroplastía of Collis to later extend to the esophagus and the total or partial funduplicatura, without tension on the esophagus. Although with the coming of the laparoscopia no longer this surgery is so necessary. When the surgical indication is by ERGE, all these procedures offer a lightening of the symptoms of ebb tide in a 80% to the 100% of the patients, still in long term pursuit (80%-90% to 10 years). The coming and development of the surgical procedures antiebb tide by laparoscópica route, with minimum mortality (0-0,5%), low morbidity (2-13%) and with equal security and effectiveness that the procedures by technique opened, in addition to smaller postsurgical pain, smaller hospital stay and smaller labor incapacity, offer the best surgical option for those patients with severe or associated disease to complications.

The unpredictable course of hernias paraesofágicas, has taken to consider to most of the surgeons, who all must be corrected surgically once have been diagnosed, even in absence of independent sintomatología and of its size, dice its potential of complications including the vólvulos, the throttling and gastric perforation that would force interventions of urgency which they entail greater mortality. In the case of hernias paraesofágicas, the surgical boarding by laparoscópica route is associated not only to greater technical difficulties, but to a mortality until of 2% and a greater index of postoperating complications (6-19%) that in surgery by ERGE; this has explained by the greater age and associate diseases that present/display most of these patients. An index to recurrences between the 5-10%, greater one appears in addition than the reported thing for surgery by open technique.

At the present time it is accepted that the surgical procedure must include the reduction of hernia, split of the herniario coat, correction of the diafragmático defect, and most of the authors they defend the accomplishment of a procedure antiebb tide, based on that two thirds of the patients with hernia paraesofágica have objective evidence of ERGE, in addition when mobilizing the hiatus probably alter to the intrinsic mechanisms antiebb tide.

Postoperatorio

In general on the following day the patient: He initiates with diet eliminates. At noon soft diet. To the 3 to 4 days normal diet. It can be withdrawn to his address. As far as the annoyances they are not different from any intervention by Laparasocopy, nevertheless combined to this can have a sensation of "I obstruct" of the foods same that will disappear after 3 to 4 weeks. In general it can initiate its normal activities at the end of the second week after the surgery. Something very important is that the patient no longer will be subject to no type of medicines and will be able to ingest any type of food.