Different Types of Hiatal Hernias and Treatments

What is a hiatal hernia?

Anatomically, a hernia involves a portion of the stomach passing through an opening in the diaphragm, the muscle that supports the lungs and separates the thoracic and abdominal cavities. A hiatal hernia alters the function of the system by which the stomach opens and closes its mouth.

Different types of hiatal hernias

Type I hernia

Type I hiatal hernia accounts for 90% of cases and mainly affects obese or overweight individuals. This is due, on the one hand, to a widening of the diaphragmatic opening through which the esophagus passes and, on the other hand, to a weakening of the esophageal phrenoesophageal ligament, which connects the gastroesophageal junction to the diaphragm, at the level of the hiatus. The frequency of this problem increases with age (over 50 years) and the presence of excess weight. A hiatal hernia increases in size when intra-abdominal pressure increases, which is typical of obesity and pregnancy. In many cases, a hiatal hernia is a silent condition. In others, affected individuals may experience specific symptoms related to digestive difficulties. Things become more complicated when the hiatal hernia is accompanied by gastroesophageal reflux, with stomach acids rising and reaching the esophagus, causing inflammation (esophagitis). The hernia itself promotes this situation. In this case, you may experience heartburn, a sensation of regurgitation, and chest pain in the ribs. A hiatal hernia can also cause a painful symptom under the right rib. This type of hernia is often reversible without requiring surgery.

Type II hernia

Paraesophageal hernia or type II hernia is characterized by the upper part of the stomach being trapped in the chest cavity. It forms because, through the esophageal hiatus, the esophagogastric junction, the esophagus, and a part of the stomach migrate and remain inside the thorax. The hernia is then compressed between the esophagus and the walls of the hiatus, which can create problems with blood circulation in the stomach. Of all hernias, this is the least frequent (5%). Again, symptoms may be negligible, but the likelihood of esophageal problems is higher.

Type III hernia

Mixed or complicated hernia (type III), as its name suggests, is characterized by the fact that it presents both paraesophageal and sliding characteristics. This type of hernia can take several forms: there are even situations where the entire stomach herniates into the chest cavity. It is highly probable that this type of hernia will cause problems and that treatment will be necessary, often involving surgery. Complicated hernias are however very rare.

Type IV hernia

Type IV hernia presents a situation where, in addition to the stomach, other viscera such as the colon and spleen are trapped in the chest.

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Treatments and remedies for hiatal hernia

Treating hiatal hernia through diet

Initial therapy begins with nutrition and involves a number of simple measures such as following a balanced diet. For heartburn and esophagitis, the remedies to consider are consistent with those for hiatal hernia. It is useful to avoid bending over, doing abdominal exercises, and wearing tight belts and girdles, which increase abdominal pressure and cause reflux.

Pharmacological treatment of hiatal hernia

From a pharmacological point of view, the patient should discuss with their doctor the appropriateness and nature of the medications to take, taking into account other ongoing therapies that may be among the triggers of the disorder. Certain active ingredients, such as NSAIDs (non-steroidal anti-inflammatory drugs such as aspirin and ibuprofen), reduce the protection of the stomach lining and increase the risk of bleeding. Antispasmodics for the intestines, calcium channel blockers used in cardiology, and some antidepressants weaken the muscles that form the lower part of the esophagus. There are also effective medications to reduce acid secretion by the stomach, while others increase muscle tone in the lower part of the esophagus, thus reducing reflux. Medications used to counteract stomach acidity (antacids) not only reduce symptoms but also allow the regeneration of the suffering esophageal mucosa. Medications that increase the protection of the esophageal mucosa can be associated with these.

Surgical treatment of hiatal hernia

Hiatal hernia is an anatomical condition and, as such, can only be treated by surgery, but even this solution can work if it is part of a range of activities:

• Lifestyle changes;
• Medical therapy;
• Surgical therapy.

Considered a panacea and capable of solving this problem on its own, surgery can also become unnecessary.

The presence of a hiatal hernia is not sufficient reason to justify surgery. In most cases, hiatal hernia disorders can be controlled by lifestyle measures and medication. When diet and appropriate drug treatment do not improve symptoms, surgical treatment can be used.

One of the most commonly used surgical approaches is the Nissen-Rossetti fundoplication, which is performed laparoscopically, i.e., through small incisions. The surgical procedure involves repositioning the stomach in the abdominal cavity, anatomically and functionally reconstructing the esophageal hiatus and the esophagogastric junction, and constructing a valve that helps the lower esophageal sphincter prevent gastroesophageal reflux. The procedure is performed under general anesthesia and requires a few days of hospitalization, a few weeks to return to work, and a few months to recover from side effects such as:

• Bloating;
• Flatulence;
• Difficulty swallowing.

Consequences of untreated hiatal hernia

In the majority of cases, a small hernia causes no problems and can be ignored for a lifetime. Many patients are diagnosed quite accidentally during medical examinations for other reasons. A large hernia, on the other hand, promotes the return of food and stomach acids to the esophagus, causing heartburn and other symptoms which, depending on their intensity, can affect the patient's quality of life in various ways. The likelihood of more serious problems developing from this type of hernia is very low, and it is often possible to regain a good quality of life by taking small daily precautions and possibly using medication.

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