Here, the upper part of the stomach slides up into the chest through the natural defect (hiatus) that exists in the diaphragm, a thin sheet like muscle which separates the chest from the abdomen. The hiatus allows the oesophagus to pass through into the abdomen.
The diaphragm is working constantly, night and day. It is essential for breathing, swallowing, coughing, sneezing and belching and vomiting. In fact, anytime we put any strain on our abdomen, the diaphragm is also working on the inside.
A tough but flexible tissue (phreno-oesophageal ligament) attaches the oesophagus to the diaphragm, and because of constant use, thousands of times a day, every day, wear and tear occurs and the tissue stretches, allowing the width of the defect to increase and the stomach to start sliding up into the chest where it lies alongside the oesophagus.
The accurate term for this condition is a para-oesophageal hernia, and there are four stages I – IV, depending on how extensive the herniation is. The old-fashioned terms of sliding, rolling and mixed hiatus hernia are sometimes still used but can be confusing. Types III and IV are occasionally referred to as “giant hiatus hernia”.
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Small (Type I) hiatus hernias may not cause any problems, and are often reported as incidental finding during routine endoscopy. However, some of these can contribute to reflux symptoms as the diaphragm, along with the lower oesophageal sphincter form the barrier mechanism to prevent stomach contents escaping into the lower oesophagus.
Reflux damage can also make the hiatus hernia worse, as the inflammation causes further weakening of the tissues, and may also scar the oesophagus, shortening it and pulling the stomach upwards
As the hiatus hernia gets bigger (Type II and III), more of the stomach starts to migrate into the chest, and sometimes it can get stuck here (incarcerated). Symptoms generally get much worse, with symptoms including difficulty in swallowing, chest pain, regurgitation, choking, coughing, shortness of breath and chest infections. The stomach is now obstructing the oesophagus and preventing food and liquid from entering it, some of which can back-flow into the breathing system. The stomach in the chest is compressed and this may result in inflammation and even ulceration causing bleeding and anaemia.
In some instances, (Type IV), other organs such as the colon and small bowel may enter the chest and cause more problems. Like any other hernia, strangulation (loss of blood supply) may occur which is an emergency.