The term “hiatal hernia” is frequently discussed in the bariatric field because morbidly obese patients are at a heightened risk for developing this condition.
Definition:
When part of the stomach pushes up from the abdomen into the chest, it is termed as a Hiatus Hernia (HH).
When 30% or more of the stomach from the abdomen enters into the chest it is termed a Giant Hiatus Hernia (GHH), accounting for approximately 5 to 10% of all hiatal hernias in general. However, GHH is more common in the obese compared to non-obese.
Cause of GHH in Obese
The causes of Hiatal hernia development are many, here we will be discussing the association between obesity and giant hiatus hernia development.
Excess weight significantly increases, and like all muscles, the muscles of the diaphragm are also subjected to this raised intra-abdominal pressure leading to weakening of the muscles of the diaphragm. The diaphragm, which is designed to keep the stomach in place, is not able to withstand the constant push from below. Over time, this can result in the stomach moving out of its normal position.
Now, a hiatal hernia occurs when the raised intraabdominal pressure causes the stomach to bulge through the weakened muscle tissue of the diaphragm. When there is excessive fat around the abdomen, the lower esophageal sphincter (LES), which separates the stomach from the esophagus, can weaken. This weakening allows stomach acid and other contents to move upward into the esophagus, creating reflux and making hernia symptoms worse.
Symptoms
Common symptoms include heartburn, severe acid reflux, regurgitation, chest pain, difficulty swallowing, fullness after a meal, and shortness of breath. The increased pressure from abdominal fat can exacerbate these symptoms, leading to chronic discomfort. As more of the stomach enters the chest, it can press over the oesophagus/food pipe and obstruct the flow of food from the esophagus to the stomach, causing fullness and even vomiting. The shortness of breath is because the stomach is now in the chest and causing pressure on the heart and the lungs, not allowing the lungs to expand to the extent required. The lungs compensate by short frequent breaths. This makes the person experience shortness of breath and in severe cases even decrease their physical activity. Regurgitation of the previous night’s ingested food particles into the mouth on waking up in the morning is another symptom of a GHH and needs urgent attention as this can lead to aspiration of the food particles into the wind pipe with deleterious consequences. Very rarely, the stomach that has entered the chest can rotate along its long axis and lose its blood supply, leading to strangulation/ gangrene of the stomach which is a surgical emergency.
An even more rare emergency is when the strangulated stomach perforates in the chest causing the acid and food contents to contaminate the chest, which is life threatening and needs to be addressed surgically, immediately without delay.
Managing weight is crucial for keeping this sphincter functioning properly and preventing the formation of a hiatus hernia.
Diagnosing A GHH
A CT scan of the chest and abdomen will throw light not only in diagnosing the condition, but also will give an idea of the compression on the lungs and the resulting compromise.
An Upper GI endoscopy is helpful. Care should be taken that the person is not only on an empty stomach over 12 hours, but also ensure that the person had only liquids the previous day. This is to make sure that the stomach is empty in order to avoid aspiration.
Esophageal manometry plays a vital role in deciding the type of surgery like the extent of fundoplication
However, the routine Blood work has to be done before going in for surgery.
Prevention and Management of Giant Hiatus Hernia
Maintaining a healthy weight and eating healthy, avoiding smoking and alcohol play a vital role in reducing the risk of developing this condition.
The Link Between Giant Hiatus Hernia and Gastrointestinal Issues
For those who are obese and have already developed a hiatal hernia, steps taken to reduce weight stand at the foremost of tackling Hiatal hernia and its related symptoms. Significant weight reduction can reduce the pressure placed on the abdomen, preventing the stomach from pushing through the diaphragm into the chest. Weight reduction also allows the LES between the stomach and the oesophagus to function in a better way thus reducing to an extent the reflux of acid from the stomach into the oesophagus.
Besides this, taking prokinetics, proton pump inhibitors, and antacids to relieve the symptoms of reflux are necessary. Having small meals helps in relieving symptoms to some extent. Taking a walk after a meal and raising the head end of the bed while sleeping can reduce the acid and/or food particles from entering the oesophagus.
If all the above is not relieving the symptoms of reflux and regurgitation of food particles into the food pipe which may eventually lead to choking by allowing food paticles to enter into the wind pipe, then surgery is the next and mandatory step.
Surgery for hiatal hernia in the obese
This can be tailor-made and requires a detailed discussion with your doctor. This is because the approach can be twofold:
- Just addressing the Hiatus hernia: Laparoscopic Fundoplication with crural repair This involves 3 steps. First, bringing the stomach which has entered into the chest back to its position in the abdomen. Second, repairing the weakened muscles of the diaphragm. Third, preventing the stomach from entering the chest due to the raised intraabdominal pressure (which is the main cause in the obese) by wrapping the fundus of the stomach over the lower end of the food pipe/ oesophagus. The wrap could be 360 degree Nissen’s Fundoplication or 270degree Toupet fundoplication.
The chances of recurrence of the hiatus hernia with the symptoms of reflux are very high as the problem of raised intraabdominal pressure is not yet dealt with.
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2. Addressing the Hiatus hernia and obesity (Raised intra abdominal pressure) as well: When dealing with a hiatal hernia or a giant hiatal hernia in obese individuals, it is very important to keep in mind the main cause, which is the raised intraabdominal pressure.
Addressing obesity along with the hiatus hernia repair is the better option to avoid recurrence. A Laparoscopic Roux en Y gastric bypass to reduce weight and avoid reflux of acid from the stomach into the oesophagus along with crural repair of the muscles of the diaphragm is a valid option. This will help in weight reduction which in turn reduces the intraabdominal pressure on the stomach. This also diverts the acid from the stomach into the jejunum which is a part of the small intestine, thus avoiding reflux.
Conclusion: A Giant Hiatus hernia (GHH) is a problem that needs to be addressed surgically. The earlier the better, to get the best results and to avoid recurrence. In the obese, Obesity as well as the GHH if addressed together is a wise option.