Hiatal Hernia

What is a hiatal hernia?

The diaphragm is a powerful muscular sheet that separates the body into two compartments: the thorax and the abdomen. A hiatal hernia occurs when part of the stomach moves into the thorax due to the enlargement of the opening (hiatus) in the diaphragm through which the esophagus passes from the thorax to the abdomen and connects with the stomach.

Increased pressure in the abdomen causes a portion of the stomach to push through the diaphragm into the thoracic cavity.

What causes a hiatal hernia?

The most common cause of hiatal hernia is increased pressure in the abdominal cavity. (The abdomen contains the lower part of the esophagus, stomach, small intestine, colon, rectum, liver, gallbladder, pancreas, spleen, kidneys, and bladder.) Pressure can arise from coughing, vomiting, straining during bowel movements, lifting heavy objects, or physical exertion. Pregnancy, obesity, or excess fluid in the abdominal cavity can also lead to hiatal hernia.

Who is at risk of developing a hiatal hernia?

Hiatal hernias can develop in individuals of all ages and genders, though they are often seen in people aged 50 and older. Hiatal hernias occur more frequently in overweight individuals and smokers.

What are the symptoms of a hiatal hernia?

Many people with a hiatal hernia never experience symptoms. Some individuals with a hiatal hernia have some symptoms of gastroesophageal reflux disease (GERD). GERD occurs when digestive fluids move from the stomach into the esophagus. Symptoms of GERD include:

• Heartburn
• Bitter or sour taste in the throat
• Bloating and belching
• Discomfort or pain in the stomach or esophagus

Although there appears to be a connection between hiatal hernias and GERD, one condition does not seem to cause the other. Many people have a hiatal hernia without GERD, and others have GERD without a hiatal hernia.

Another symptom of a hiatal hernia is chest pain. Since chest pain can also be a symptom of heart-related issues, it is important to contact your doctor or go to the emergency department if you experience chest pain.

How is a hiatal hernia diagnosed?

Several tests can contribute to the diagnosis of a hiatal hernia. These include:

• Barium swallow X-ray: This uses X-rays to help diagnose conditions in the esophagus (such as swallowing disorders) and stomach (such as ulcers and tumors). It also shows how large the hiatal hernia is and whether there is any twisting of the stomach as a result of the hernia.
• Esophagogastroduodenoscopy (EGD): An examination where the interior of the upper gastrointestinal tract is inspected using an endoscope (a long, thin, flexible instrument about 1 cm in diameter).
• Esophageal manometry: Measures the strength and coordination of the esophageal muscles during swallowing.
• pH monitoring: Measures acid levels in the esophagus and helps determine which symptoms are related to acid in the esophagus.
• Gastric emptying study: Examines how quickly food leaves the stomach. Results from this test are particularly important in patients who experience nausea and vomiting. There may be other causes of nausea and vomiting besides a hiatal hernia.

How is a hiatal hernia treated?

Most cases do not cause problems and rarely require treatment. However, since some patients with a hiatal hernia experience symptoms of GERD, treatment begins with methods used to manage GERD. These include lifestyle changes such as:

• Weight loss if overweight
• Reducing meal sizes
• Avoiding certain acidic foods like tomato sauce and citrus fruits or juices that irritate the esophagus
• Limiting fried and fatty foods, caffeine-containing foods (including chocolate), mint, carbonated drinks, alcoholic beverages, ketchup, mustard, and vinegar
• Eating meals at least three to four hours before lying down and avoiding snacks in bed
• Keeping your head 20 cm higher than the rest of your body while lying on your back. Elevating your head helps gravity keep stomach contents in the stomach.
• Quitting smoking
• Avoiding tight belts or tight clothing that may increase pressure in the abdominal area
• Taking medications after meals to reduce stomach acid. These include antacids or H2 blockers.

Note: If you take medications for more than 2 weeks without any improvement, see your doctor. They may prescribe stronger medications such as pantoprazole, rabeprazole, esomeprazole, omeprazole, or lansoprazole.

When is surgery needed for a hiatal hernia?

Surgery is required if the part of the stomach that enters the thorax is compressed so strongly that blood supply may be cut off. Surgery may also be needed for individuals with a hiatal hernia who have also experienced severe, long-lasting (chronic) gastroesophageal reflux whose symptoms are not alleviated by medical treatments. The goal of this surgery is to correct gastroesophageal reflux by creating an improved valve mechanism at the bottom of the esophagus. The valve prevents stomach contents from returning to the esophagus. If left untreated, chronic gastroesophageal reflux can lead to complications such as esophagitis (inflammation), esophageal ulcers, bleeding, or scarring of the esophagus.

When is surgery needed for a hiatal hernia?

Surgery is required if the part of the stomach that enters the thorax is compressed so strongly that blood supply may be cut off. Surgery may also be needed for individuals with a hiatal hernia who have also experienced severe, long-lasting (chronic) gastroesophageal reflux whose symptoms are not alleviated by medical treatments. The goal of this surgery is to correct gastroesophageal reflux by creating an improved valve mechanism at the bottom of the esophagus. The valve prevents stomach contents from returning to the esophagus. If left untreated, chronic gastroesophageal reflux can lead to complications such as esophagitis (inflammation), esophageal ulcers, bleeding, or scarring of the esophagus.

How is surgery for a hiatal hernia performed?

The surgery involves pulling the hiatal hernia back into the abdomen and creating an improved valve mechanism at the bottom of the esophagus by closing the opening in the diaphragm muscle. The surgeon wraps the upper part of the stomach (called the fundus) around the lower part of the esophagus. This creates a permanent new sphincter so that stomach contents do not reflux back into the esophagus.

Two approaches for the surgery can be taken. One is an “open” procedure, which is done through large incisions. The second is a “minimally invasive” procedure, which is done through several small incisions. The minimally invasive procedure is called laparoscopic fundoplication.

During laparoscopic surgery, five or six tiny incisions are made in the abdomen. The laparoscope and surgical instruments are inserted through these incisions. The surgeon guides the laparoscope, which transmits images of the internal organs to a monitor. Advantages of laparoscopic surgery compared to “open” surgery include smaller incisions, less risk of infection, less pain and scarring, and quicker recovery.

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