Hiatal Hernia

The diaphragm is a sheet of muscle that separates the abdomen from the chest cavity. It has an opening in the middle called the hiatus. The food pipe, or esophagus, runs through the hiatus in order for it to enter into the stomach. When the hiatus is enlarged, the stomach can bulge up into the chest causing symptoms such as heartburn, regurgitation, reflux, chest pain, and trouble swallowing.

There are several types of hiatal hernias (aka paraesophageal hernias):

The first type of hiatal hernia is called a sliding hiatal hernia. This is the most common type of hiatal hernia and is a result of the lower esophagus and top of the stomach sliding up together into the chest through the hiatus.

Other, less common types of hiatal hernias are called paraesophageal hernias. These occur when a section of the stomach goes up into the chest next to the esophagus, or when other organs such as colon, intestine, or spleen go up through the hernia defect into the chest. These types of hernia can be more dangerous because they are not always associated with symptoms and can result in the stomach tissue becoming twisted off from its blood supply resulting in “strangulation” of the stomach. In most cases, however, people have mild symptoms such as heartburn or gastroesophageal reflux disease (GERD) due to the structural changes associated with the hiatal or paraesophageal hernia.

There are many factors that can result in a hiatal hernia, but for most patients, the cause is unknown. It is possible that some people are simply born with a short esophagus or a large hiatus, or develop these conditions over time due to weakened tissue, or chronic scarring of the lining of the lower esophagus from acid reflux resulting in contraction or shortening of the overall esophageal length. Other causes include increased intra-abdominal pressure in the abdomen due to conditions such as obesity, pregnancy, chronic cough or straining during bowel movements. Experts also predict that patients who have gained a considerable amount of weight are at risk for hiatal hernia development, along with people over the age of 50 and people that are smokers.

Hiatal hernias occur more often in women, people who are overweight, and people older than 50.

It is not uncommon for people to have no symptoms associated with their hiatal hernia. When symptoms do occur, they normally consist of heartburn and gastroesophageal reflux. Other symptoms may include pain or discomfort in the stomach or upper abdomen, chest pain, a harsh or sour taste in the back of the throat, as well as bloating and even excessive belching.

Chest pain due to a hiatal hernia feels very similar to that experienced during a heart attack. It is crucial to seek evaluation and treatment immediately so that you can be correctly diagnosed and treated.

Symptoms of a strangulated hiatal hernia or associated obstruction include: abdominal pain, the inability to have a bowel movement (constipation), the inability to pass gas, or development of persistent nausea and vomiting.

A barium swallow study, which is a specific X-ray procedure, can enable the proper evaluation of the esophagus to correctly diagnose a hiatal hernia. Other ways to diagnose a hiatal hernia are by CT scan or esophagoscopy (EGD). The esophagoscopy is a procedure where an endoscope, a long-thin flexible medical video camera, is inserted through the mouth into the esophagus and stomach and allows the examination of the upper digestive system.

Hernia surgery is not necessary when patients do not have any associated symptoms.  For mild symptoms such as bloating or heartburn there are often ways a hiatal hernia can be treated through healthy lifestyle changes. These changes include maintaining a healthy weight, limiting fatty, acidic, and caffeinated foods, along with avoiding alcoholic beverages and quitting smoking.  It is also recommended that the person avoid eating at least 2-3 hours before going to bed and elevating their head while sleeping to reduce the amount of acid exposure into the lower esophagus. Other treatments include taking antacids to chemically neutralize stomach acid, thereby reducing heartburn symptoms.  For patients with persistent heartburn symptoms that are not well-controlled with lifestyle changes, or for patients whom antacids no longer work well, surgical evaluation is warranted.

Patients who suffer the following conditions along with a hiatal hernia may be required to undergo surgical repair:

• Gastroesophageal reflux or GERD with symptoms including regurgitation, hoarseness, and/or heartburn that is no longer responsive to acid-blocking medications.
• Strangulated hernia or obstruction – symptoms including abdominal pain, inability to have a bowel movement or pass gas, or persistent nausea and vomiting.  A strangulated hernia is an emergency situation, and often requires an emergency operation.