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
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There are two types of hiatal hernias (see Figure 18-3):FIGURE 18-3 Hiatal hernia. (A), sliding hernia; (B), paraesophageal hernia.
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Sliding hernia: Stomach and gastroesophageal junction slip up into the chest (most common)
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Paraesophageal hernia (rolling hernia): Part of the greater curvature of the stomach rolls through the diaphragmatic defect
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Caused by muscle weakening due to aging or other conditions, such as esophageal carcinoma or trauma, or following certain surgical procedures
Clinical Manifestations
Diagnostic Evaluation
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Barium study of the esophagus outlines hernia.
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Endoscopic examination visualizes defect.
Management
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Elevation of head of bed (6 to 8 inches [15 to 20 cm]) to reduce nighttime reflux.
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Antacid therapy to neutralize gastric acid.
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H2-receptor antagonist (cimetidine, ranitidine) if patient has esophagitis.
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Surgical repair of hernia if symptoms are severe.
Complications
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Aspiration of reflux contents
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Ulceration, hemorrhage
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Gastritis
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Stricture
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Incarceration of the portion of the stomach in the chest
Nursing Interventions and Patient Education
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Instruct patient on the prevention of reflux of gastric contents into esophagus by:
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Eating smaller meals.
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Avoiding stimulation of gastric secretions by omitting caffeine and alcohol.
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Refraining from smoking.
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Avoiding fatty foods: promote reflux and delay gastric emptying.
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Refraining from lying down for at least 1 hour after meals.
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Losing weight, if obese.
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Avoiding bending from the waist and/or wearing tight-fitting clothes.
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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.
