Is hiatal hernia a serious problem?

I am a 55-year-old male who is about 30 pounds overweight. Lately I’ve been experiencing frequent heartburn and have an acid taste in the back of my throat. My wife says it’s probably a hiatal hernia. Is this a serious problem? Will it require surgery?

A hernia is the pressing of an organ through an abdominal opening in the muscle wall of the cavity that protects it. With a hiatal hernia, a portion of the stomach pushes through a teardrop-shaped hole where the esophagus and the stomach join.

The most common cause of a hiatal hernia is an increase in pressure on the abdominal cavity. Pressure can come from coughing, vomiting, straining during a bowel movement, heavy lifting, or physical strain. Pregnancy, obesity, or excess fluid in the abdomen also contribute to hiatal hernias.

A hiatal hernia can develop in people of all ages and both sexes, although it frequently affects middle-aged people. In fact, the majority of otherwise healthy people over age 50 have small hiatal hernias.

Many people with a hiatal hernia never have any symptoms at all. In some people, acid and digestive juices escape from the stomach into the esophagus (gastroesophageal reflux). This causes:

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

Most hiatal hernias do not cause problems and rarely need treatment.

Successful treatment of hiatal hernias usually involves treating the symptoms of gastroesophageal reflux disease (GERD) that are triggered by the additional pressure in the abdomen.

Treatment includes making lifestyle changes, such as:

  • Losing weight if you are overweight, and maintaining a healthy weight
  • Having a common sense approach to eating, such as eating moderate to small portions of foods; and limiting fatty foods, acidic foods (such as tomatoes and citrus fruits or juices), foods containing caffeine, and alcoholic beverages
  • Eating meals at least 3-4 hours before lying down, and avoiding bedtime snacks
  • Elevating the head of your bed by 6 inches (this helps allow gravity to keep the stomach's contents in the stomach)
  • Not smoking
  • Taking medications, such as over-the-counter antacids, Gaviscon, or H2 blockers (such as Pepcid AC or Zantac)

Note: If you take over-the-counter medications for longer than two weeks without any improvement, see your physician. Your physician can prescribe a stronger medication, and/or pantoprazole (Protonix), rabeprazole (Aciphex), esomeprazole (Nexium), H2-receptor antagonists, proton pump inhibitors (omeprazole [Prilosec], lansoprazole [Prevacid]).

If medications are not effective in treating your symptoms, diagnostic tests may be performed to determine if surgery is necessary. Surgery is rarely needed to correct the disorder.

I have a hiatal hernia and am wondering if there is an operation or other permanent solution.

To treat a hiatal hernia, your doctor might first recommend the following management techniques:

  • Taking medications after eating to reduce acid in the stomach
  • Decreasing the size of portions during meals
  • Losing weight, if overweight
  • Quitting smoking
  • Avoiding certain acidic foods that irritate the esophageal lining
  • Avoiding caffeine (including chocolate), alcohol, nicotine, and fatty foods
  • Sitting up during meals and not bending over, lying down, or going to bed for 2 to 3 hours after eating
  • Elevating the head of the bed 6 inches while sleeping

People with a hiatal hernia who also have severe, chronic esophageal reflux may need surgery to correct the problem if their symptoms are not relieved through these management techniques.

Surgery may also be needed to reduce the size of the hernia if it is in danger of becoming constricted or strangulated (so that the blood supply is cut off).

During surgery, gastroesophageal reflux is corrected by pulling the hiatal hernia back into the abdomen and creating an improved valve mechanism at the bottom of the esophagus. The surgeon wraps the upper part of the stomach (called the fundus) around the lower portion of the esophagus. This creates a permanently tight sphincter so that food will not reflux back into the esophagus.

Hiatal hernia surgery can be performed as a laparoscopic or "minimally invasive" procedure. During laparoscopic surgery, five or six small (5 to 10 millimeter) incisions are made in the abdomen. The laparoscope and surgical instruments are inserted through these incisions. The surgeon is guided by the laparoscope, which transmits a picture of the internal organs on a monitor. The advantages of laparoscopic surgery include smaller incisions, less risk of infection, less pain and scarring, and a more rapid recovery.