A hiatal hernia occurs when the upper part of the stomach pushes upward through the diaphragm via a small opening called the hiatus. This common condition often causes no symptoms or only mild issues like chronic heartburn. However, a strangulated hiatal hernia is a rare, acute, and life-threatening complication. The sudden onset of severe symptoms indicates that the herniated tissue is compromised and requires immediate medical intervention.
Understanding the Critical Difference
When a portion of the stomach or other abdominal organs becomes trapped above the diaphragm, it is referred to as an incarcerated hernia. In this state, the tissue is stuck, but the blood flow to the trapped organs generally remains intact.
The situation becomes a strangulated hernia when the blood supply to the herniated tissue is completely cut off. This vascular compromise can happen due to severe compression or if the trapped stomach portion twists, known as gastric volvulus. Without blood supply, the tissue begins to die, leading to tissue necrosis.
The Acute Symptoms of Strangulation
The symptoms of a strangulated hiatal hernia differ significantly from the mild discomfort associated with a simple hiatal hernia. The onset is marked by sudden, intense, and unremitting pain, often felt in the chest or upper abdomen. This pain may radiate to the back or shoulder and is constant, rapidly escalating unlike the intermittent pain of acid reflux.
Intractable nausea and forceful vomiting that does not relieve the pain are common. If the trapped tissue is part of the intestine, signs of complete gastrointestinal obstruction will appear, including the inability to pass gas or have a bowel movement. Vomiting blood or dark material, sometimes described as coffee grounds, is a concerning sign of bleeding within the gastrointestinal tract.
As the affected tissue begins to die, the body responds with systemic signs of infection and shock. These signs include a rapid heart rate and a fever. The patient may also exhibit signs of shock, such as clammy skin, confusion, and low blood pressure. These systemic symptoms signal that necrotic tissue is releasing toxins into the bloodstream, which can quickly progress to sepsis.
Emergency Medical Intervention
Recognizing these acute symptoms requires immediate activation of emergency medical services, as every hour of delay increases the risk of serious complications. Upon arrival at the emergency room, the medical team focuses on rapid diagnosis and stabilization. Imaging tests, such as a computed tomography (CT) scan or an X-ray, are typically used to confirm the diagnosis and determine the extent of obstruction or tissue damage.
The definitive treatment for a strangulated hiatal hernia is emergency surgery. During the procedure, which may be performed using open or minimally invasive techniques, the surgeon aims to reduce the hernia. This involves gently returning the trapped portion of the stomach or intestine back into the abdominal cavity to restore blood flow to the compromised tissue.
If the herniated tissue has already suffered irreversible damage, the surgeon must remove the necrotic section. Failure to urgently address the blood flow cutoff can lead to tissue perforation, releasing infectious contents into the chest or abdomen and increasing the risk of sepsis and death. Following the reduction of the hernia, the surgeon will repair the defect in the diaphragm, often using sutures or surgical mesh to prevent recurrence.