Hiatal hernia: Nursing process (ADPIE)

Mary Fowler, aged 68, presents to the emergency department, or ED, with vomiting and abdominal pain and distention.

Mary has a history of a paraesophageal hiatal hernia with symptoms of gastroesophageal reflux disease, or GERD, which she normally manages with lifestyle modifications and acid-reducing medications.

Her symptoms worsened over the last 2 days, and she has been unable to keep food or liquid down over the last 24 hours.

Mary is diagnosed with a large incarcerated paraesophageal hiatal hernia, confirmed with an abdominal X-ray and computerized tomography, or CT scan.

She will be cared for in the ED while she awaits surgical repair of her hernia.

A hiatal hernia occurs when part of the stomach moves up, or herniates, into the chest through the hiatus, which is the opening in the diaphragm for the esophagus as it enters the abdominal cavity.

Underneath the diaphragm, the esophagus then connects with the stomach to form the gastroesophageal junction and the lower esophageal sphincter, or LES, a ring of muscles that opens to allow food and liquids into the stomach and closes to keep gastric contents from coming back up through the esophagus.

There are two main types of hiatal hernias.

The most common type is a sliding hernia, where the gastroesophageal junction slides up and down through the hiatus.

Less common are paraesophageal hernias, where parts of the stomach roll up through the hiatus, forming a pocket next to the esophagus.

The risk of developing a hiatal hernia increases if the diaphragm is weakened from trauma, abdominal surgery, or smoking.

Likewise, anything that increases pressure inside the abdomen, like coughing, obesity, pregnancy, straining, or heavy lifting increases the risk of hernia development.

The risk also increases with age due to age-related widening of the hiatus, or in those who are born with an unusually large hiatal opening.

Because hiatal hernias can interfere with the function of theLES, signs and symptoms are often similar to GERD.

Acidic gastric contents can reflux into the esophagus and cause heartburn and pain in the upper abdomen or chest.

Stomach acid can also reflux up into the larynx, irritating the vocal folds and causing hoarseness.

If gastric contents are aspirated into the airway, it can cause respiratory complications such as pneumonia or asthma-like symptoms.

Persistent reflux can lead to esophageal inflammation, or esophagitis, and it can even erode the lining of the esophagus, creating an ulcer, which can lead to bleeding or perforation.

Fibrosis or scarring can occur, resulting in esophageal narrowing, or strictures, which makes swallowing difficult.

Eventually, the cells lining the esophagus change, a condition known as Barrett’s esophagus, which is associated with a higher risk of esophageal adenocarcinoma.

Now, a hiatal hernia can become incarcerated, meaning the herniated part of the stomach becomes trapped between structures in the chest cavity, like between the diaphragm, esophagus, and lungs.

If the blood flow to the hernia is cut off, the hernia becomes strangulated, which then lends to ischemia and necrosis and clinical manifestations like pain, difficulty swallowing, and vomiting.

Strangulation of any hernia is a surgical emergency that requires immediate treatment.

A rare and life-threatening complication of a hiatal hernia is the formation of a gastric volvulus.

Seen more often with paraesophageal hernias, this involves the stomach twisting on itself more than 180 degrees with the hiatus acting as a pivot point.

This results in complete obstruction and strangulation.

Clinical manifestations include abdominal pain and distention along with retching without vomiting.

A gastric volvulus is a surgical emergency.

Diagnosis of a hiatal hernia is based on the client’s medical history and physical examination.

CT scanning can visualize part of the stomach in the chest.

A barium X-ray, also known as an upper GI series, or direct visualization with an upper endoscopy are also used.

Supportive care and symptom management are often the treatments for GERD, including lifestyle changes and acid-reducing medications.

Antireflux surgery, known as Nissen fundoplication, is often required for symptomatic cases.