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01.03 Hiatal Hernia

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Overview

  1. Protrusion of stomach through the diaphragm into thorax

Nursing Points

General

  1. Caused by weakening of muscles in the diaphragm
  2. Diagnosis
    1. Barium swallow x-ray shows reflux into esophagus
    2. Endoscopy

Assessment

  1. Heartburn
    1. Differentiate between heartburn and cardiac chest pain
  2. Regurgitation
  3. Dysphagia
  4. Hiccups & Belching
  5. Fullness
    1. Feel like food gets “stuck”
  6. Bowel sounds over chest
    1. Peristalsis

Therapeutic Management

  1. Similar to GERD
  2. Avoid medications that delay gastric emptying (anticholinergics)
  3. Antacids, H2 Receptor Antagonists, or PPI’s if experiencing reflux
  4. Weight loss can naturally improve hiatal hernia
  5. Surgical Repair
    1. Physically pull stomach from diaphragm
    2. Nissen Fundoplication
      1. Create a new esophagogastric junction to prevent slipping

Nursing Concepts

  1. Comfort
    1. Sleep with HOB elevated
    2. Avoid straining
    3. Avoid vigorous exercise
  2. Nutrition
    1. Eat small, frequent meals
    2. Do not lay down for 1 hour after eating

Patient Education

  1. Follow dietary instructions
  2. Take medications as prescribed

Reference Links

Study Tools

Video Transcript

Let’s talk about hiatal hernias.

A hiatal hernia is when a portion of the stomach protrudes upwards through the diaphragm into the thorax. What happens is that the muscles in the diaphragm get weak and the opening where the esophagus enters is not as tight. So some portion of the stomach, or in really severe cases, the majority of it, will protrude up into the chest cavity. So you can imagine how you might feel if part of your stomach is constricted up through the diaphragm like this.

One of the main things patients will present with is heartburn. See there’s usually a sphincter here between the esophagus and the stomach. As the stomach protrudes through the diaphragm it can weaken and damage that sphincter, so patients can get gastric acid refluxing into their esophagus. So you’ll see symptoms very similar to GERD. They’ll get some regurgitation and dysphagia and a lot of times they’ll have frequent belching or hiccups because of the pressure on the diaphragm. The other thing you see quite often is a feeling of fullness or like something is stuck. I actually had a student approach me in clinical once and she joked that she might be having a heart attack. She said “I’m having terrible heartburn, I’ve tried drinking water and that just makes it worse, and I feel like stuff’s just getting stuck right here” and she pointed to her lower chest. I had a feeling it might be this, so I got out my stethoscope and listened over her chest and sure enough, I heard bowel sounds over her chest. I straight up said “I’m no doctor, but you have the classic signs of a hiatal hernia”. So why bowel sounds over the chest? That seems weird right? Well if you think about it, what we’re hearing in bowel sounds is the sound of peristalsis, which is the muscles moving to move food along the GI tract. Well the stomach has peristalsis as well. So when the stomach protrudes into the chest cavity, you’re going to be able to hear those sounds where they normally wouldn’t be. To diagnose this, we can do x-rays, especially with barium contrast to see where the liquid is collecting, or we could do an endoscopy to see what’s going on.

Managing Hiatal hernias is very similar to GERD, so review that lesson if you need to. We avoid anticholinergics because they slow down gastric motility and we want things moving forward. We’ll also give meds for reflux like antacids, H2 receptor antagonists (those are your -dines), and proton pump inhibitors (those are your -prazoles). The other thing that tends to help is weight loss. Many times this is caused by obesity because of the extra intra abdominal pressure caused by the amount of fat present, it actually pushes the stomach upward. So weight loss tends to help the stomach fall back into place. It can also be caused by excessive coughing or vomiting, so we do want to be sure to address that cause as well. In terms of repair, sometimes it can be corrected with a simple endoscopy, but usually it requires surgical intervention. They can actually physically go in and pull the stomach down, or they can do what’s called a Nissen Fundoplication. We do this when that esophagogastric sphincter has been so badly damaged that it would just be a recurring problem and they’d have serious reflux. My husband actually had to have this done. He developed a severe hiatal hernia after a terrible stomach virus that left him unable to keep anything down for a week. They basically grab the top of the stomach and wrap it around the esophagus and suture it to itself. Not only does this create a new sphincter, but it also forms somewhat of an anchor to keep it from going back upwards through the diaphragm.

When it comes to nursing care, our big priorities are decreasing their pain and dealing with their nutritional restrictions. We want to teach them not to lie down within an hour or two of eating. The reflux can be worse when lying down, so if they eat and then lay flat, their pain will be worse. On the same lines, we can encourage them to elevate their head while sleeping, or we can do so with the hospital bed. When this gets really bad, many patients end up sleeping in a recliner or on the couch to decrease their pain and other symptoms. When it comes to nutrition, we want to encourage smaller meals, and smaller bites! Big bites and big gulps of liquid can get stuck in the portion of the stomach that’s protruding and they can cause vomiting. Patients need to eat less, eat slower, and eat smaller bites. We also encourage them to avoid too much straining or vigorous exercise – that pressure in the abdomen can cause the stomach to push further into the chest cavity.

Again, keep in mind your priority nursing concepts for a patient with a Hiatal Hernia are going to be comfort and nutrition. Make sure you check out the care plan attached to this lesson to see more specific nursing interventions and rationales.

So let’s recap. A hiatal hernia occurs when the stomach protrudes through the diaphragm because of weak muscles in the diaphragm. This is going to constrict that part of the stomach and make eating and drinking uncomfortable. Think of it like trying to fill up a water balloon with a rubber band around the neck. The rubber band is going to restrict filling and prevent it from expanding. You’ll probably lose some water out the top. So patients experience that reflux and feeling like food is stuck in their esophagus. We manage this similarly to GERD by giving medications to decrease the acid in the stomach and we have surgical options to repair the hiatal hernia, like a nissen fundoplication. We want to encourage patients to take smaller bites and eat smaller meals slower to help manage their pain and reflux. We also want to encourage them to keep their head elevated for at least an hour after eating.

So that’s it for hiatal hernia, make sure you check out the resources attached to this lesson to learn more! Now, go out and be your best selves today. And, as always, happy nursing!

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