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Hiatus hernia in children.

THE term congenital diaphragmatic hernia tends to be applied to the dramatic herniation of small intestine and other abdominal organs through the foramen of Bochdalek into the left pleural cavity with consequent acute respiratory disturbances. Such children commonly present as acute emergencies during the first few days of life. However, hiatus hernia is also frequently of congenital origin and this is not only a much more common condition but also one that can lead to much more morbidity and even mortality. Hiatus hernia can be defined as a displacement of the cardio-oesophageal junction above the level of the diaphragm, or a protrusion of part of the stomach through the oesophageal hiatus. Both these types of the abnormality have been demonstrated in the newly born and are being demonstrated with increasing frequency in young children. It is difficult to regard similar conditions presenting in older patients as an entirely different disease but at the same time an explanation must be given to the fact that so many of these cases do not present until the patients reach the age of 50-60 years. The diagnosis can only be made positively by demonstrating cardiooesophageal displacement or herniation of the stomach through the oesophageal hiatus; such demonstration may be achieved at necropsy, at surgical exploration or at radiological examination. The reported incidence of the condition thus tends to vary with the enthusiasm of the radiologist and the availability of special equipment but there is no doubt that continuing improvement in radiological techniques have brought to light many more cases of hiatus hernia in children than had previously been demonstrated as well as many more cases occurring in adults. The increased frequency with which supradiaphragmatic pouches of stomach have been demonstrated on radiological examination has led to an acceptance of the idea that gastro-oesophageal reflux in the newly born and young child is probably an early stage of hiatus hernia; indeed it might be that a hiatus hernia was present but had not been demonstrated. Both in adults and children it is increasingly accepted that the actual hiatus hernia is of far less importance than the consequent functional disturbance at the cardio-oesophageal junction leading to free gastro-oesophageal reflux, oesophagitis and possibly oesophageal stricture.