The esophagus enters the abdomen through an opening in the di-aphragm and empties at its lower end into the upper part of the stomach. Normally, the opening in the diaphragm encircles the esophagus tightly, and the stomach lies completely within the ab-domen. In a condition known as hiatus (or hiatal) hernia, the opening in the diaphragm through which the esophagus passes becomes enlarged, and part of the upper stomach tends to move up into the lower portion of the thorax. Hiatal hernia occurs more often in women than men. There are two types of hiatal hernias: sliding and paraesophageal. Sliding, or type I, hiatal her-nia occurs when the upper stomach and the gastroesophageal junction (GEJ) are displaced upward and slide in and out of the thorax (Fig. 35-8A). About 90% of patients with esophageal hi-atal hernia have a sliding hernia. A paraesophageal hernia occurs when all or part of the stomach pushes through the diaphragm beside the esophagus (see Fig. 35-8B). Paraesophageal hernias may be further classified as types II, III, or IV, depending on the extent of herniation, with type IV having the greatest herniation.
The patient with a sliding hernia may have heartburn, regurgi-tation, and dysphagia, but at least 50% of patients are asymp-tomatic. Sliding hiatal hernia is often implicated in reflux. The patient with a paraesophageal hernia usually feels a sense of full-ness after eating or may be asymptomatic. Reflux usually does not occur, because the gastroesophageal sphincter is intact. The complications of hemorrhage, obstruction, and strangulation can occur with any type of hernia.
Diagnosis is confirmed by x-ray studies, barium swallow, and fluoroscopy.
Management for an axial hernia includes frequent, small feedings that can pass easily through the esophagus. The patient is advised not to recline for 1 hour after eating, to prevent reflux or move-ment of the hernia, and to elevate the head of the bed on 4- to 8-inch (10- to 20-cm) blocks to prevent the hernia from sliding upward. Surgery is indicated in about 15% of patients. Medical and surgical management of a paraesophageal hernia is similar to that for gastroesophageal reflux; however, paraesophageal hernias may require emergency surgery to correct torsion (twisting) of the stomach or other body organ that leads to restriction of blood flow to that area.