HH are more common in Western countries. Burkitt and James suggest that the Western, fiber-depleted diet leads to a state of chronic constipation and straining during bowel movement, which could explain the higher incidence of this condition in Western countries. Hiatal hernias are more common in women than in men. The frequency of HH increases with age, from 10% in patients younger than 40 years to 70% in patients older than 70 years.
HH is classified into two types depending on the position of the gastroesophageal (GE) junction and the extent of herniated stomach: sliding hernias and paraesophageal hernias. Type I, also called sliding hernias, occurs when the GE junction migrates through the hiatus into the posterior mediastinum. It is the most common type, accounting for 85–95% of all the cases. Types II, III, and IV, also called paraesophageal hernias, are less common and account for the remaining 5–15% of the cases [10, 11]. Type II occurs when the GE junction is in its normal position and the fundus herniates through the hiatus along its side. Type III is a combination of types I and II wherein there is a protrusion of the stomach through the hiatus along with a displaced GE junction. Type IV is defined by herniation of the stomach with other organs into the chest.
HH may be asymptomatic or patients might complain of heartburn, belching, dysphagia, abdominal pain, nausea, chest pain, or cough. In most patients, the cause of the HH is unknown. Some people are born with a weakness or an especially large hiatus. It is believed that increased pressure in the abdomen from chronic coughing, straining during bowel movements, pregnancy and delivery, obesity, and abdominal ascites may contribute to the development of the HH. Rarely, iatrogenic or traumatic diaphragmatic hernia (DH) may occur. They account for less than 1% of all the DH . Iatrogenic hernias can occur due to alterations in the normal anatomy from surgical dissection of the hiatus. This may be due to disruption of a previous hiatal closure, postoperative gastric dilatation, disruption of the phrenoesophageal membrane by operative dissection, and failure to recognize esophageal shortening or an existing hiatal defect . Etiologies of iatrogenic diaphragmatic defects include Ivor Lewis procedure, antireflux procedures, esophagomyotomy, partial gastrectomy, gastric banding procedures, and misguided chest tubes or thoracoabdominal incisions in which the diaphragm is taken down .
HH can be complicated by intermittent bleeding episodes from associated esophagitis, erosions, and esophageal ulcers; iron deficiency anemia; incarceration; strangulation and perforation. Acute pancreatitis complicating a diaphragmatic hernia is rare and multiple theories have been proposed to explain it. Acute pancreatitis occurring in the case of a pancreatic hernia may be caused by repetitive trauma as it crosses the hernia, ischemia associated with stretching at its vascular pedicle, [15, 16], or intermittent folding of the main pancreatic duct. Total incarceration of the pancreas may also contribute to pancreatitis.
Signs and symptoms of pancreatic cancer
Most cancers of the pancreas are adenocarcinomas. Early cancer of the pancreas may cause no symptoms. When symptoms occur, they are often vague at first and may depend on where in the pancreas the cancer is. The commonest symptoms are pain typically in the upper central abdomen but can be any part of teh abdomen, back pain, loss of appetite and loss of weight and steatorrhoea (see below). The symptoms experienced with other forms of pancreatic cancer may be different.
The pain often starts as general discomfort or pain in the abdomen (tummy) which can spread to the back. Early on the pain may come and go but it can become persistent as the disease develops. Pain is often described as getting worse after meals or by lying down. Some patients have pain at night and disturbed sleep. Sometimes they report pain as a pulled muscle or as joint or bone pain.
The most common sign of this type of pancreatic cancer is jaundice. This is most likely to occur when the cancer is in the head of the pancreas. People with jaundice may have yellow skin, yellow eyes, dark urine, pale stools and an itchy skin. Other symptoms can include nausea and sickness and changes to bowel habit. There may be general abdominal discomfort.
Weight loss is a common symptom of pancreatic cancer. This may be because of poor absorption of food, poor appetite, nausea, and sickness. Other symptoms can be indigestion and bloating of the stomach, particularly after meals. People may also feel very tired. This may be due to loss of muscle strength.
An urgent ultrasound scan if CT is not available, to assess for pancreatic cancer in people aged 60 and over with weight loss and any of the following:
• back pain
• abdominal pain
• new onset diabetes.”
Other people we talked to remembered more unusual symptoms. Michael said that after drinking wine he would wake in the night with indigestion and ‘the shivers’ and that he would sweat for the next 12 hours. Maureen said that she felt as though she had ‘an alien’ just under her ribs.
There are less common types of pancreatic cancer, such as the neuroendoncrine tumours, which produce an excess of hormones, such as insulin. This may lead to weak or dizzy feelings, chills, muscle spasms, or diarrhoea. Others (non-functioning islet cell tumours) do not produce excessive amounts of hormones in the blood, and can grow for a long time before doctors make a diagnosis.