Pressure-Overload-Induced Sliding Hiatal Hernia in Power Athletes

Abstract

Sliding hiatal hernias are a common condition thought to occur with increasing age secondary to a degenerative process. The incidence of sliding hiatal hernias in the general population is 0.5%. Although the prevalence in the Western world is thought to be significantly higher, with approximately 60% of geriatric patients in North America having a hiatal hernia on radiologic studies. Thus, the primary etiology of the sliding hiatal hernia is thought to be degeneration of the phrenoesophageal ligament. Most hiatal hernias occurring in young adults are idiopathic. There has been speculation of a stress-induced hiatal hernia from repeated episodes of elevated intra-abdominal pressure, and to date there is one report of a pressure-overload-induced hiatal hernia occurring in an elite body builder. The prevalence of hiatal hernia in young male power athletes has yet to be examined. Therefore, we examined eight male elite power athletes and seven male non-weightlifters, matched for age, via fluoroscopy with barium swallow to test the hypothesis that pressure overload can induce hiatal hernias in young adults.

Struggling with a Gastric Volvulus Secondary to a Type IV Hiatal Hernia

“…Their etiology is usually unclear; they are mainly acquired disorders resulting from the combination of an enlarged diaphragmatic hiatus with repeated episodes of elevated intraabdominal pressure [4]. Anatomical stressors, such as heavy weight lifting or even daily activities, can increase the intraabdominal pressure forcing mobile abdominal organs through the hiatus into the chest cavity [5]. Our patient was a former professional wrestler, thus explaining the long history of repeated episodes of elevated intraabdominal pressure which could predispose to hiatal hernia formation.…”

Clinical Significance of Hiatal Hernia

“…However, the phrenoesophageal ligament/membrane becomes progressively lax by losing the amount of elastic tissues with aging, possibly through wear and tear due to repetitive stress of swallowing, thus predisposing to the development of hiatal hernia 20,21. Loss of elasticity of the phrenoesophageal ligament/membrane may also be caused by excessive contraction of the esophageal longitudinal muscle, increased abdominal pressure as occurs in power atheletes,22 pregnancy,23 genetic predisposition,24,25 and previous surgery. Some propose that instead of hiatal hernia being the cause of reflux esophagitis, reflux esophagitis itself is the primary culprit that initiates and sustains the esophagitis-hernia complex; a study with opossums showed that acidification of the esophageal mucosa induced longitudinal muscle contraction, resulting in shortening of the esophagus 26-28…”

Gastroesophageal Reflux Disease

“…Animal studies propose that reflux itself causes esophageal shortening, promoting the development of a hiatus hernia [38]. Other studies find an association with obesity [39] and lifting of heavy weights [40], raising the possibility that, over time, chronic intraabdominal stressors may weaken the esophageal hiatus and may cause the development of a hiatus hernia. This theory is attractive because it helps to reconcile the increased prevalence of hiatus hernias as the population ages [34].…”