Hiatal hernia

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Hiatal hernia
Other namesHiatus hernia
Hiatalhernia.gif
A drawing of a hiatal hernia
Specialty Gastroenterology, general surgery
Symptoms Taste of acid in the back of the mouth, heartburn, trouble swallowing [1]
Complications Iron deficiency anemia, volvulus, bowel obstruction [1]
TypesSliding, paraesophageal [1]
Risk factors Obesity, older age, major trauma [1]
Diagnostic method Endoscopy, medical imaging, manometry [1]
TreatmentRaising the head of the bed, weight loss, medications, surgery [1]
Medication H2 blockers, proton pump inhibitors [1]
Frequency10–80% (US) [1]

A hiatal hernia or hiatus hernia [2] is a type of hernia in which abdominal organs (typically the stomach) slip through the diaphragm into the middle compartment of the chest. [1] [3] This may result in gastroesophageal reflux disease (GERD) or laryngopharyngeal reflux (LPR) with symptoms such as a taste of acid in the back of the mouth or heartburn. [1] [3] Other symptoms may include trouble swallowing and chest pains. [1] Complications may include iron deficiency anemia, volvulus, or bowel obstruction. [1]

Contents

The most common risk factors are obesity and older age. [1] Other risk factors include major trauma, scoliosis, and certain types of surgery. [1] There are two main types: sliding hernia, in which the body of the stomach moves up; and paraesophageal hernia, in which an abdominal organ moves beside the esophagus. [1] The diagnosis may be confirmed with endoscopy or medical imaging. [1] Endoscopy is typically only required when concerning symptoms are present, symptoms are resistant to treatment, or the person is over 50 years of age. [1]

Symptoms from a hiatal hernia may be improved by changes such as raising the head of the bed, weight loss, and adjusting eating habits. [1] Medications that reduce gastric acid such as H2 blockers or proton pump inhibitors may also help with the symptoms. [1] If the condition does not improve with medications, a surgery to carry out a laparoscopic fundoplication may be an option. [1] Between 10% and 80% of adults in North America are affected. [1]

Signs and symptoms

Hiatal Hernia.png
Hiatal hernia

Hiatal hernia has often been called the "great mimic" because its symptoms can resemble many disorders. Among them, a person with a hiatal hernia can experience dull pains in the chest, shortness of breath (caused by the hernia's effect on the diaphragm), heart palpitations (due to irritation of the vagus nerve), and swallowed food "balling up" and causing discomfort in the lower esophagus until it passes on to the stomach. In addition, hiatal hernias often result in heartburn but may also cause chest pain or pain with eating. [1]

In most cases, however, a hiatal hernia does not cause any symptoms. The pain and discomfort that a patient experiences is due to the reflux of gastric acid, air, or bile. While there are several causes of acid reflux, it occurs more frequently in the presence of hiatal hernia.

In newborns, the presence of Bochdalek hernia can be recognised [4] from symptoms such as difficulty breathing, [5] fast respiration, and increased heart rate. [6]

Causes

The following are potential causes of a hiatal hernia. [7]

Obesity and age-related changes to the diaphragm are also general risk factors.

Diagnosis

The diagnosis of a hiatal hernia is typically made through an upper GI series, endoscopy, high resolution manometry, esophageal pH monitoring, and computed tomography (CT). Barium swallow as in upper GI series allows the size, location, stricture, stenosis of oesophagus to be seen. It can also evaluate the oesophageal movements. Endoscopy can analyse the esophageal internal surface for erosions, ulcers, and tumours.

Meanwhile, manometry can determine the integrity of esophageal movements, and the presence of esophageal achalasia. pH testings allows the quantitative analysis of acid reflux episodes. CT scan is useful in diagnosing complications of hiatal hernia such as gastric volvulus, perforation, pneumoperitoneum, and pneumomediastinum. [8]

Classification

Schematic diagram of different types of hiatus hernia. Green is the esophagus, red is the stomach, purple is the diaphragm, blue is the HIS-angle. A is the normal anatomy, B is a pre-stage, C is a sliding hiatal hernia, and D is a paraesophageal (rolling) type. Hiatus hernia.svg
Schematic diagram of different types of hiatus hernia. Green is the esophagus, red is the stomach, purple is the diaphragm, blue is the HIS-angle. A is the normal anatomy, B is a pre-stage, C is a sliding hiatal hernia, and D is a paraesophageal (rolling) type.

Four types of esophageal hiatal hernia are identified: [10]

Type I: A type I hernia, also known as a sliding hiatal hernia, occurs when part of the stomach slides up through the hiatal opening in the diaphragm. [11] There is a widening of the muscular hiatal tunnel and circumferential laxity of the phrenoesophageal ligament, allowing a portion of the gastric cardia to herniate upward into the posterior mediastinum. The clinical significance of type I hernias is in their association with reflux disease. Sliding hernias are the most common type and account for 95% of all hiatal hernias. [12] (C)

Type II: A type II hernia, also known as a paraesophageal or rolling hernia, occurs when the fundus and greater curvature of the stomach roll up through the diaphragm, forming a pocket alongside the esophagus. [11] It results from a localized defect in the phrenoesophageal ligament while the gastroesophageal junction remains fixed to the pre aortic fascia and the median arcuate ligament. The gastric fundus then serves as the leading point of herniation. Although type II hernias are associated with reflux disease, their primary clinical significance lies in the potential for mechanical complications. (D)

Type III: Type III hernias have elements of both types I and II hernias. With progressive enlargement of the hernia through the hiatus, the phrenoesophageal ligament stretches, displacing the gastroesophageal junction above the diaphragm, thereby adding a sliding element to the type II hernia.

Type IV: Type IV hiatus hernia is associated with a large defect in the phrenoesophageal ligament, allowing other organs, such as colon, spleen, pancreas and small intestine to enter the hernia sac.

The end stage of type I and type II hernias occurs when the whole stomach migrates up into the chest by rotating 180° around its longitudinal axis, with the cardia and pylorus as fixed points. In this situation the abnormality is usually referred to as an intrathoracic stomach.

Treatment

In the great majority of cases, people experience no significant discomfort, and no treatment is required. People with symptoms should elevate the head of their beds and avoid lying down directly after meals. [1] If the condition has been brought on by stress, stress reduction techniques may be prescribed, or if overweight, weight loss may be indicated.

Medications

Antisecretory drugs such as proton pump inhibitors and H2 receptor blockers can be used to reduce acid secretion. Medications that reduce the lower esophageal sphincter (LES) pressure should be avoided.[ citation needed ]

Procedures

There is tentative evidence from non-controlled trials that oral neuromuscular training may improve symptoms. [13] This has been approved by the UK National Health Service for supply on prescription from 1 May 2022. [14]

Surgery

In some unusual instances, as when the hiatal hernia is unusually large, or is of the paraesophageal type, it may cause esophageal stricture or severe discomfort. About 5% of hiatal hernias are paraesophageal. If symptoms from such a hernia are severe for example if chronic acid reflux threatens to severely injure the esophagus or is causing Barrett's esophagus, surgery is sometimes recommended. However surgery has its own risks including death and disability, so that even for large or paraesophageal hernias, watchful waiting may on balance be safer and cause fewer problems than surgery. [15] Complications from surgical procedures to correct a hiatal hernia may include gas bloat syndrome, dysphagia (trouble swallowing), dumping syndrome, excessive scarring, and rarely, achalasia. [15] [16] Surgical procedures sometimes fail over time, requiring a second surgery to make repairs.

One surgical procedure used is called Nissen fundoplication. In fundoplication, the gastric fundus (upper part) of the stomach is wrapped, or plicated, around the inferior part of the esophagus, preventing herniation of the stomach through the hiatus in the diaphragm and the reflux of gastric acid. The procedure is now commonly performed laparoscopically. With proper patient selection, laparoscopic fundoplication studies in the 21st century have indicated relatively low complication rates, quick recovery, and relatively good long term results. [17] [18] [19] [20] Regarding the discussion of partial versus complete fundoplication procedures, significant variations in the postoperative outcome emphasize the increased prevalence of dysphagia after Nissen. The statistics given support the superiority of laparoscopic over traditional surgery, owing to the greater aesthetic result, shorter admission time – with lower costs – and faster social reintegration. [21]

Epidemiology

Incidence of hiatal hernias increases with age; approximately 60% of individuals aged 50 or older have a hiatal hernia. [22] Of these, 9% are symptomatic, depending on the competence of the lower esophageal sphincter (LES). 95% of these are "sliding" hiatal hernias, in which the LES protrudes above the diaphragm along with the stomach, and only 5% are the "rolling" type (paraesophageal), in which the LES remains stationary, but the stomach protrudes above the diaphragm.[ citation needed ]

Hiatal hernias are most common in North America and Western Europe and rare in rural African communities. [23] Some have proposed that insufficient dietary fiber and the use of a high sitting position for defecation may increase the risk. [24]

Veterinary

Hiatal hernia has been described in small animals since 1974, with the first case being in two dogs. It has since been reported in cats too. Type I is the most common and Type II is also common, but III and IV are rare with scarce reports in the literature. [25]

In dogs it is estimated 60% of cases are congenital with brachycephalic breeds being the most affected due to the oesophageal hiatus' cross-sectional area being larger than normocephalic and doliocephalic dogs. The diaphragm failing to fuse during development of the embryo is believed to be the cause of congenital hiatal hernia. [25]

The Shar-pei and Bulldog are most commonly affected, however no mutation or heritability has been identified as of 2023. Other risk factors for the condition include: nasal masses, laryngeal paralysis, and a narrowed intrapharyngeal opening. [25]

Tetanus has been identified as a cause in dogs; these cases can be resolved via treating the tetanus. [25]

Treatment of airway obstructions and feeding low-fat more digestible food can alleviate any need for invasive procedures. [25]

Related Research Articles

<span class="mw-page-title-main">Hernia</span> Abnormal exit of tissues or organs from the cavity they usually reside in

A hernia is the abnormal exit of tissue or an organ, such as the bowel, through the wall of the cavity in which it normally resides. The term is also used for the normal development of the intestinal tract, referring to the retraction of the intestine from the extra-embryonal navel coelom into the abdomen in the healthy embryo at about 7½ weeks.

<span class="mw-page-title-main">Esophagus</span> Vertebrate organ through which food passes to the stomach

The esophagus or oesophagus, colloquially known also as the food pipe, food tube, or gullet, is an organ in vertebrates through which food passes, aided by peristaltic contractions, from the pharynx to the stomach. The esophagus is a fibromuscular tube, about 25 cm (10 in) long in adults, that travels behind the trachea and heart, passes through the diaphragm, and empties into the uppermost region of the stomach. During swallowing, the epiglottis tilts backwards to prevent food from going down the larynx and lungs. The word oesophagus is from Ancient Greek οἰσοφάγος (oisophágos), from οἴσω (oísō), future form of φέρω + ἔφαγον.

<span class="mw-page-title-main">Esophageal achalasia</span> Inability of the sphincter between the esophagus and stomach to open

Esophageal achalasia, often referred to simply as achalasia, is a failure of smooth muscle fibers to relax, which can cause the lower esophageal sphincter to remain closed. Without a modifier, "achalasia" usually refers to achalasia of the esophagus. Achalasia can happen at various points along the gastrointestinal tract; achalasia of the rectum, for instance, may occur in Hirschsprung's disease. The lower esophageal sphincter is a muscle between the esophagus and stomach that opens when food comes in. It closes to avoid stomach acids from coming back up. A fully understood cause to the disease is unknown, as are factors that increase the risk of its appearance. Suggestions of a genetically transmittable form of achalasia exist, but this is neither fully understood, nor agreed upon.

Heartburn, also known as pyrosis, cardialgia or acid indigestion, is a burning sensation in the central chest or upper central abdomen. Heartburn is usually due to regurgitation of gastric acid into the esophagus. It is the major symptom of gastroesophageal reflux disease (GERD).

Heller myotomy is a surgical procedure in which the muscles of the cardia are cut, allowing food and liquids to pass to the stomach. It is used to treat achalasia, a disorder in which the lower esophageal sphincter fails to relax properly, making it difficult for food and liquids to reach the stomach.

An esophageal motility disorder (EMD) is any medical disorder resulting from dysfunction of the coordinated movement of esophagus, which causes dysphagia.

<span class="mw-page-title-main">Gastroesophageal reflux disease</span> Flow of stomach contents into the esophagus

Gastroesophageal reflux disease (GERD) or gastro-oesophageal reflux disease (GORD) is a chronic upper gastrointestinal disease in which stomach content persistently and regularly flows up into the esophagus, resulting in symptoms and/or complications. Symptoms include dental corrosion, dysphagia, heartburn, odynophagia, regurgitation, non-cardiac chest pain, extraesophageal symptoms such as chronic cough, hoarseness, reflux-induced laryngitis, or asthma. In the long term, and when not treated, complications such as esophagitis, esophageal stricture, and Barrett's esophagus may arise.

<span class="mw-page-title-main">Barrett's esophagus</span> Precancerous tissue formation in the esophagus

Barrett's esophagus is a condition in which there is an abnormal (metaplastic) change in the mucosal cells lining the lower portion of the esophagus, from stratified squamous epithelium to simple columnar epithelium with interspersed goblet cells that are normally present only in the small intestine and large intestine. This change is considered to be a premalignant condition because of its potential to further transition to esophageal adenocarcinoma, an often-deadly cancer.

<span class="mw-page-title-main">Esophagitis</span> Inflammation of the esophagus

Esophagitis, also spelled oesophagitis, is a disease characterized by inflammation of the esophagus. The esophagus is a tube composed of a mucosal lining, and longitudinal and circular smooth muscle fibers. It connects the pharynx to the stomach; swallowed food and liquids normally pass through it.

<span class="mw-page-title-main">Nissen fundoplication</span> Surgical procedure to treat gastric reflux and hiatal hernia

A Nissen fundoplication, or laparoscopic Nissen fundoplication when performed via laparoscopic surgery, is a surgical procedure to treat gastroesophageal reflux disease (GERD) and hiatal hernia. In GERD, it is usually performed when medical therapy has failed; but, with a Type II (paraesophageal) hiatus hernia, it is the first-line procedure. The Nissen fundoplication is total (360°), but partial fundoplications known as Thal, Belsey, Dor, Lind, and Toupet fundoplications are alternative procedures with somewhat different indications and outcomes.

<span class="mw-page-title-main">Mallory–Weiss syndrome</span> Medical condition

Mallory–Weiss syndrome is a condition where high intra-abdominal pressures causes laceration and bleeding of the mucosa called Mallory-Weiss tears. Additionally, Mallory–Weiss syndrome is one of the most common causes of acute upper gastrointestinal bleeding, counting of around 1-15% of all cases in adults and less than 5% in children. It has been found that tears are up to 2 to 4 times more prevalent in men than women. The tears can cause upper gastrointestinal bleeding and predominantly occur where the esophagus meets the stomach. However, the tears can happen anywhere from the middle of the esophagus to the cardia of the stomach. Mallory–Weiss syndrome is often caused by constant vomiting and retching from alcoholism or bulimia. Gastroesophageal reflux disease (GERD) is another risk factor that is often linked with Mallory–Weiss syndrome. However, not every individual with Mallory–Weiss syndrome will have these risk factors. Individuals with Mallory–Weiss syndrome will have hematemesis, however the symptoms can vary.

<span class="mw-page-title-main">Laparoscopic hiatal hernia repair</span> Medical procedure

Laparoscopic hernia repair is the repair of a hiatal hernia using a laparoscope, which is a tiny telescope-like instrument. A hiatal hernia is the protrusion of an organ through its wall or cavity. There are several different methods that can be used when performing this procedure. Among them are the Nissen Fundoplication and the general laparoscopic hernia repair.

Stretta is a minimally invasive endoscopic procedure for the treatment of gastroesophageal reflux disease (GERD) that delivers radiofrequency energy in the form of electromagnetic waves through electrodes at the end of a catheter to the lower esophageal sphincter (LES) and the gastric cardia – the region of the stomach just below the LES. The energy heats the tissue, ultimately causing it to swell and stiffen; the way this works was not understood as of 2015, but it was thought that perhaps the heat causes local inflammation, collagen deposition and muscular thickening of the LES and that it may disrupt the nerves there.

Roemheld syndrome (RS), or gastrocardiac syndrome, or gastric cardiac syndrome or Roemheld–Techlenburg–Ceconi syndrome or gastric-cardia, was a medical syndrome first coined by Ludwig von Roemheld (1871–1938) describing a cluster of cardiovascular symptoms stimulated by gastrointestinal changes. Although it is currently considered an obsolete medical diagnosis, recent studies have described similar clinical presentations and highlighted potential underlying mechanisms.

A Cameron lesion is a linear erosion or ulceration of the mucosal folds lining the stomach where it is constricted by the thoracic diaphragm in persons with large hiatal hernias. The lesions may cause chronic blood loss resulting in iron deficiency anemia; less often they cause acute bleeding.

<span class="mw-page-title-main">Esophageal pH monitoring</span> Method of diagnosing and measuring gastric acid reflux

In gastroenterology, esophageal pH monitoring is the current gold standard for diagnosis of gastroesophageal reflux disease (GERD). It provides direct physiologic measurement of acid in the esophagus and is the most objective method to document reflux disease, assess the severity of the disease and monitor the response of the disease to medical or surgical treatment. It can also be used in diagnosing laryngopharyngeal reflux.

The Sugiura procedure is a surgical technique that involves the removal and transection of the blood vessels that supply the upper portion of the stomach and the esophagus. The procedure also involves a splenectomy. The operation was originally developed to treat bleeding esophageal varices that were untreatable by other conventional methods. It was originally developed as a two-step operation, but has been modified numerous times by many surgeons since its original creation.

Transoral incisionless fundoplication (TIF) is an endoscope treatment designed to relieve symptoms of gastroesophageal reflux disease (GERD). The TIF procedure, similar to Nissen fundoplication, alleviates GERD symptoms by wrapping a portion of the stomach around the esophagus.

Esophagogastric junction outflow obstruction (EGJOO) is an esophageal motility disorder characterized by increased pressure where the esophagus connects to the stomach at the lower esophageal sphincter. EGJOO is diagnosed by esophageal manometry. However, EGJOO has a variety of etiologies; evaluating the cause of obstruction with additional testing, such as upper endoscopy, computed tomography, or endoscopic ultrasound may be necessary. When possible, treatment of EGJOO should be directed at the cause of obstruction. When no cause for obstruction is found, observation alone may be considered if symptoms are minimal. Functional EGJOO with significant or refractory symptoms may be treated with pneumatic dilation, per-oral endoscopic myotomy (POEM), or botulinum toxin injection.

<span class="mw-page-title-main">Stomach reduction surgery</span>

Stomach reduction surgery, also known as bariatric surgery, is a medical procedure aimed at facilitating weight loss by reducing the size of the stomach, thereby limiting food intake and promoting satiety with smaller portions. It is frequently used for cases where traditional weight loss approaches, consisting of diet and physical activity, have proven insufficient, or when obesity already significantly affects well-being and general health.

References

  1. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Roman, S; Kahrilas, PJ (23 October 2014). "The diagnosis and management of hiatus hernia". BMJ (Clinical Research Ed.). 349: g6154. doi:10.1136/bmj.g6154. PMID   25341679. S2CID   7141090. However, the exact prevalence of hiatus hernia is difficult to determine because of the inherent subjectivity in diagnostic criteria. Consequently, estimates vary widely—for example, from 10% to 80% of the adult population in North America
  2. ↑ "Hiatus hernia - Illnesses & conditions". NHS inform. Retrieved 10 May 2022.
  3. 1 2 "Hiatal Hernia". PubMed Health. Archived from the original on 28 April 2017.
  4. ↑ Chang SW, Lee HC, Yeung CY, Chan WT, Hsu CH, Kao HA, Hung HY, Chang JH, Sheu JC, Wang NL (2010). "A twenty-year review of early and late-presenting congenital Bochdalek diaphragmatic hernia: are they different clinical spectra?". Pediatr Neonatol. 51 (1): 26–30. doi: 10.1016/S1875-9572(10)60006-X . PMID   20225535.
  5. ↑ Ganeshan DM, Correa AM, Bhosale P, Vaporciyan AA, Rice D, Mehran RJ, Walsh GL, Iyer R, Roth JA, Swisher SG, Hofstetter WL (2013). "Diaphragmatic hernia after esophagectomy in 440 patients with long-term follow-up". Ann Thorac Surg. 96 (4): 1138–45. doi: 10.1016/j.athoracsur.2013.04.076 . PMID   23810174.
  6. ↑ Alam, A; Chander, B.N. (July 2005). "Adult bochdalek hernia". MJAFI. 61 (3): 284–6. doi:10.1016/S0377-1237(05)80177-7. PMC   4925637 . PMID   27407781.
  7. ↑ "Hiatal hernia - Symptoms and causes". Mayo Clinic .
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  9. 1 2 "UOTW #39 - Ultrasound of the Week". Ultrasound of the Week. 25 February 2015. Archived from the original on 9 May 2017. Retrieved 27 May 2017.
  10. ↑ Kahrilas, Peter J.; Kim, Hyon C.; Pandolfino, John E. (2008). "Approaches to the diagnosis and grading of hiatal hernia". Best Practice & Research Clinical Gastroenterology. 22 (4): 601–616. doi:10.1016/j.bpg.2007.12.007. PMC   2548324 . PMID   18656819.
  11. 1 2 Lewis, Sharon Mantik; Bucher, Linda; Heitkemper, Margaret M.; Harding, Mariann; Kwong, Jeffery; Roberts, Dottie (2017). Medical-surgical nursing: assessment and management of clinical problems (10th ed.). St. Louis, Missouri: Elsevier. ISBN   978-0-323-32852-4. OCLC   944472408.
  12. ↑ Dennis Kasper; Anthony Fauci; Stephen Hauser; Dan Longo; J. Larry Jameson; Joseph Loscalzo (8 April 2015). Harrison's Principles of Internal Medicine, 19e (19 ed.). McGraw-Hill Global Education. p. 1902. ISBN   978-0-07-180215-4.
  13. ↑ Clinical and technical evidence - IQoro for hiatus hernia (Report). National Institute for Health and Care Excellence. 6 March 2019. MIB176.
  14. ↑ "Innovative IQoro neuromuscular treatment device achieves NHS prescription status". Advances in Clinical Neuroscience and Rehabilitation (ACNR). 25 March 2022.
  15. 1 2 Stylopoulos N, Gazelle GS, Rattner DW (2002). "Paraesophageal hernias: operation or observation?". Ann Surg. 236 (4): 492–500. doi:10.1097/00000658-200210000-00012. PMC   1422604 . PMID   12368678.
  16. ↑ Laparoscopic Nissen fundoplication - Information for patients (PDF) (Report). Oxford University Hospitals NHS. December 2021. OMI68160.
  17. ↑ Migaczewski M, Pędziwiatr M, Matłok M, Budzyński A (2013). "Laparoscopic Nissen fundoplication in the treatment of Barrett's esophagus — 10 years of experience". Wideochir Inne Tech Maloinwazyjne. 8 (2): 139–45. doi:10.5114/wiitm.2011.32941. PMC   3699774 . PMID   23837098.
  18. ↑ Witteman BP, Strijkers R, de Vries E, Toemen L, Conchillo JM, Hameeteman W, Dagnelie PC, Koek GH, Bouvy ND (2012). "Transoral incisionless fundoplication for treatment of gastroesophageal reflux disease in clinical practice". Surg Endosc. 26 (11): 3307–15. doi:10.1007/s00464-012-2324-2. PMC   3472060 . PMID   22648098.
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  20. ↑ Abbas AE, Deschamps C, Cassivi SD, Allen MS, Nichols FC, Miller DL, Pairolero PC (2004). "Barrett's esophagus: the role of laparoscopic fundoplication". Ann. Thorac. Surg. 77 (2): 393–6. doi: 10.1016/S0003-4975(03)01352-3 . PMID   14759403.
  21. ↑ Lucenco, L.; Marincas, M.; Cirimbei, C.; Bratucu, E.; Ionescu, S. (2012). "The 10 years' experience in the laparoscopic treatment of benign pathology of the eso gastric junction". Journal of Medicine and Life. 5 (2): 179–184. PMC   3391883 . PMID   22802887.
  22. ↑ Goyal Raj K, "Chapter 286. Diseases of the Esophagus". Harrison's Principles of Internal Medicine, 17e.
  23. ↑ Burkitt DP (1981). "Hiatus hernia: is it preventable?". Am. J. Clin. Nutr. 34 (3): 428–31. doi: 10.1093/ajcn/34.3.428 . PMID   6259926.
  24. ↑ Sontag S (1999). "Defining GERD". Yale J Biol Med. 72 (2–3): 69–80. PMC   2579007 . PMID   10780568.
  25. 1 2 3 4 5 Monnet, Eric; Bright, Ronald (31 May 2023). "Hiatal hernia". Small Animal Soft Tissue Surgery. Hoboken, NJ: John Wiley & Sons. pp. 29–36. ISBN   978-1-119-69368-0.
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