1. HIATAL HERNIA
BY: MUTHANNA AL-LAMI

2. Objectives Introduction Types Etiology Pathophysiology Symptoms
Diagnosis
Differential diagnosis
Treatment
Complications

3. Introduction
The hiatus is an opening in the diaphragm -- the muscular wall separating the chest cavity from the abdomen. Normally, the esophagus goes through the hiatus and attaches to the stomach.
Hiatal hernia (hiatus hernia) :is the protrusion of the stomach upward into the medistinal cavity through the esophageal hiatus .

4. Types There are two main types of hiatal hernias: sliding .
paraesophageal (next to the esophagus).

5. sliding hiatal hernia: the stomach and the section of the esophagus that joins the stomach slide up into the chest through the hiatus. This is the more common type of hernia.(90%).
The paraesophageal hernia: is less common (10%) , but is more cause for concern. The esophagus and stomach stay in their normal locations, but part of the stomach squeezes through the hiatus, landing it next to the esophagus. Although the patient can have this type of hernia without any symptoms, the danger is that the stomach can become "strangled," or have its blood supply shut off.

6. Etiology
The exact etiology is unknown but Increased pressure within the abdomen caused by :
Heavy lifting or hard coughing
Hard sneezing
Pregnancy and delivery
Vomiting
Constipation and obesity
all those might lead to herniation .

7. Pathophysiology

8. In sliding hiatal hernia, the displacement of the gastroesophageal junction above the diaphragm decreases the lower esophageal sphincter (LES) pressure. Because the LES is the primary determinant of the antireflux valve, a decrease in LES pressure predisposes the patient to gastroesophageal reflux. 
The situation for paraesophageal hernia differs in that the rotation and twisting of the stomach as it migrates into the chest can produce intermittent strangulation with obstruction and ischemia. This can result in pain, vomiting, ulcers, and necrosis.

9. Symptoms Small hernias- usually asymptomatic .
Large hernias –can cause :
Heartburn
Dysphagia
Regurgitation
Chest pain
Nausea and vomiting .
Belching

10. Diagnosis

11.  barium swallow involves drinking a special liquid, then taking X-rays to help see problems in the esophagus and the stomach. It also shows how big the hiatal hernia is and if there is twisting of the stomach as a result of the hernia.
 endoscopy is a procedure in which the inside of the upper digestive system is examined with an endoscope (a long, thin, flexible instrument about 1/2 inch in diameter).
CT SCAN :useful especially for evaluation of paraesophageal hernias to identify the size and other organs which may be involved.

12. Differential diagnosis

13. treatment
Medications :

14. Antacids that neutralize stomach acid
Antacids that neutralize stomach acid. Antacids, such as Mylanta, Rolaids and Tums, may provide quick relief.
Medications to reduce acid production. These medications — known as H-2-receptor blockers — include cimetidine and ranitidine (Zantac).
Medications that block acid production and heal the esophagus. These medications — known as proton pump inhibitors — are stronger acid blockers than H-2-receptor blockers and allow time for damaged esophageal tissue to heal. include lansoprazole and omeprazole (Zegerid).

15. Surgery

16. Endoluminal fundoplication

17. Nissen fundoplication is the most commonly performed surgery for a hiatal hernia. This procedure uses laparoscopic repair or keyhole surgery, it is minimally invasive and only requires the surgeon to make a few tiny incisions in the abdomen.it has some advantages over other types of hiatal hernia surgery, These include:
less risk of infection, less painful, reduced scarring,less time in the
hospital and recovery is usually quicker.
Open surgery involves making a larger incision in the abdomen so that the surgeon can fix the hernia. This procedure carries more risks than laparoscopic repair.
A surgeon will pull the stomach back into the abdominal cavity and wrap the upper portion, called the fundus, around the lower part of the food pipe. This creates a tight sphincter which stops the stomach acid from leaking up into the food pipe.

18. Edolominal fundoplication :This procedure is relatively new and is even less invasive than laparoscopic repair, though it is not commonly used. The surgeon does not need to make any incisions. Instead, they place an endoscope (a tube with a light and camera) down the throat and into the esophagus.
The surgeon tightens the area where the stomach and esophagus join to prevent reflux.

19. Lifestyle modifications
Eat several smaller meals throughout the day rather than a few large meals
Avoid foods that trigger heartburn, such as fatty or fried foods, tomato sauce, alcohol, chocolate, mint, garlic, onion, and caffeine
Avoid lying down after a meal or eating late in the day
Eat at least two to three hours before bedtime.
Maintain a healthy weight
Stop smoking
Elevate the head of your bed 6 inches (about 15 centimeters)

20. Complications Esophagitis GERD Infection Bleeding
Damage of internal organs

21. References https://www.webmd.com/digestive-disorders/hiatal-hernia#1

22. Thank you