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Monday, February 4, 2019

HIATAL HERNIA


A hiatal hernia is a protrusion of a portion of the stomach through the hiatus of the diaphragm and into the thoracic cavity.
Pathophysiology and Etiology
  • There are two types of hiatal hernias (see Figure 18-3):

    FIGURE 18-3 Hiatal hernia. (A), sliding hernia; (B), paraesophageal hernia.
    • Sliding hernia: Stomach and gastroesophageal junction slip up into the chest (most common)
    • Paraesophageal hernia (rolling hernia): Part of the greater curvature of the stomach rolls through the diaphragmatic defect
  • Caused by muscle weakening due to aging or other conditions, such as esophageal carcinoma or trauma, or following certain surgical procedures
Clinical Manifestations
  • May be asymptomatic
  • Heartburn (with or without regurgitation of gastric contents into the mouth)
  • Dysphagia, chest pain
Diagnostic Evaluation
  • Barium study of the esophagus outlines hernia.
  • Endoscopic examination visualizes defect.
Management
  • Elevation of head of bed (6 to 8 inches [15 to 20 cm]) to reduce nighttime reflux.
  • Antacid therapy to neutralize gastric acid.
  • H2-receptor antagonist (cimetidine, ranitidine) if patient has esophagitis.
  • Surgical repair of hernia if symptoms are severe.
Complications
  • Aspiration of reflux contents
  • Ulceration, hemorrhage
  • Gastritis
  • Stricture
  • Incarceration of the portion of the stomach in the chest
Nursing Interventions and Patient Education
  • Instruct patient on the prevention of reflux of gastric contents into esophagus by:
    • Eating smaller meals.
    • Avoiding stimulation of gastric secretions by omitting caffeine and alcohol.
    • Refraining from smoking.
    • Avoiding fatty foods: promote reflux and delay gastric emptying.
    • Refraining from lying down for at least 1 hour after meals.
    • Losing weight, if obese.
    • Avoiding bending from the waist and/or wearing tight-fitting clothes.
  • Advise patient to report to health care facility immediately for the onset of acute chest pain, which may indicate incarceration of a large paraesophageal hernia.

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