What is a hiatal hernia?
A hiatal hernia occurs when the upper part of the stomach pushes through an opening in the diaphragm and into the chest cavity. The diaphragm is the thin muscle wall that separates the chest cavity from the abdomen. The opening in the diaphragm is where the esophagus and stomach join.
Who is at risk for developing a hiatal hernia?
A hiatal hernia can develop in people of all ages and both sexes, although it frequently occurs in people aged 50 and older. Hiatal hernia occurs more often in people with overweight/obesity and smokers.
Symptoms and Causes
What causes a hiatal hernia?
The most common cause of a hiatal hernia is an increase in pressure in the abdominal cavity. Your abdominal cavity is the space in the middle of your body that holds several organs, including the:
- Lower part of the esophagus and stomach.
- Small intestine, colon and rectum.
- Gallbladder, pancreas and spleen.
This pressure can build up from things like:
- Straining during a bowel movement.
- Heavy lifting.
- Physical strain.
Increased pressure in the abdomen (arrows) causes part of the stomach to push through the diaphragm and into the chest cavity.
What are the symptoms of a hiatal hernia?
Many people with a hiatal hernia never have symptoms. Some people with hiatal hernia have some of the same symptoms as gastroesophageal reflex disease (GERD). GERD occurs when digestive juices move from the stomach back into the esophagus. Symptoms of GERD include:
- Bitter or sour taste in the back of the throat.
- Bloating and belching.
- Discomfort or pain in the stomach or esophagus.
Although there appears to be a link between hiatal hernia and GERD, one condition does not seem to cause the other. Many people have a hiatal hernia without having GERD, and others have GERD without having a hiatal hernia.
Another symptom of a hiatal hernia is chest pain. Since chest pain can also be a symptom of a heart attack, it’s important to contact your healthcare provider or go to the emergency room if you experience any chest pain.
Diagnosis and Tests
How is a hiatal hernia diagnosed?
Several tests can be done to help diagnose a hiatal hernia. These include a barium swallow test, an endoscopy procedure, esophageal manometric studies, a pH test and gastric emptying studies.
- A barium swallow involves drinking a special liquid, then taking X-rays to help see problems in the esophagus (such as swallowing disorders) and the stomach (such as ulcers and tumors). It also shows how big the hiatal hernia is and if there is twisting of the stomach as a result of the hernia.
- An endoscopy is a procedure in which the inside of the upper digestive system is viewed with an endoscope (a long, thin, flexible instrument about 1/2 inch in diameter).
- An esophageal manometry measures the strength and muscle coordination of your esophagus when you swallow.
- A pH test measures the acid levels in the esophagus and helps determine which symptoms are related to acid in the esophagus.
- Gastric emptying studies examine how fast food leaves the stomach. Results from this test are especially important in patients who have nausea and vomiting. There could be other causes of the nausea and vomiting besides a hiatal hernia.
Management and Treatment
How is a hiatal hernia treated?
Most hiatal hernias do not cause problems and rarely need treatment. However, since some patients with a hiatal hernia have symptoms of GERD, treatment starts with methods used to manage GERD. These include making such lifestyle changes as:
- Maintaining a weight that's healthy for you.
- Decreasing the portion sizes of meals.
- Avoiding certain acidic foods—such as tomato sauce and citrus fruits or juices—that can irritate the esophageal lining.
- Limiting fried and fatty foods, foods or drinks containing caffeine (including chocolate), peppermint, carbonated beverages, alcoholic beverages, ketchup and mustard, and vinegar.
- Eating meals at least three to four hours before lying down, and avoiding bedtime snacks.
- Keeping your head six inches higher than the rest of your body when lying on your back. Raising the level of your head helps gravity keep your stomach’s contents in the stomach. Raising the head of your bed by angling your mattress works best—piling your pillows doesn’t work as well because it makes you crunch your middle instead of simply angling your body upwards.
- Quitting smoking.
- Not wearing a tight belt or tight clothing that can increase the pressure on the abdomen — such as control top hosiery and body shapers.
- Taking medications after eating to reduce acid in the stomach. These over-the-counter medications include antacids, Gaviscon®, or H-blockers (such as Pepcid AC® or Zantac®).
Sometimes, a medication called a proton-pump inhibitor might be used to treat hiatal hernia. This medication is another way to decrease the amount of stomach acid you have, which can help prevent reflux. When you take this medication, your body doesn’t make as much stomach acid as normal. This is similar to H-blocker medications.
Can over-the-counter medications help relieve my hiatal hernia symptoms?
In many cases, over-the-counter medications can help you with some symptoms of hiatal hernia. Antacids are the most common medication you might use for relief. However, if you take over-the-counter medications for longer than two weeks without any improvement, see your healthcare provider. Prescription medications are typically the next step. These can include:
- Pantoprazole (Protonix®).
- Rabeprazole (Aciphex®).
- Esomeprazole (Nexium®).
- Omeprazole (Prilosec®).
- Lansoprazole (Prevacid®).
When is surgery for a hiatal hernia needed?
If the portion of the stomach entering the esophagus is being squeezed so tightly that the blood supply is being cut off, you’ll need to have surgery. Surgery may also be needed in people with a hiatal hernia who have severe, long-lasting (chronic) esophageal reflux whose symptoms are not relieved 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. Think of this valve as a swinging door. It opens to let food pass down into the stomach and then closes to keep stomach contents from going back up the esophagus. When this valve doesn’t work correctly, your stomach contents can go the wrong way and damage your esophagus. If left untreated, chronic gastroesophageal reflux can cause complications such as esophagitis (inflammation), esophageal ulcers, bleeding or scarring of the esophagus.
How is surgery for a hiatal hernia performed?
Surgery for repairing a hiatal hernia involves:
- Pulling the hiatal hernia back into the abdomen.
- Improving the valve at the bottom of the esophagus.
- Closing the hole in the diaphragm muscle.
During surgery, your surgeon will wrap the upper part of the stomach (called the fundus) around the lower portion of the esophagus. This creates a permanently tight sphincter (the valve) so that stomach contents will not move back (reflux) into the esophagus.
Called a fundoplication, there are two versions of this surgery. An open fundoplication surgery involves a larger incision. This type of procedure may need to be done in some very severe cases and it allows for greater visibility during surgery. However, open surgeries require a longer recovery time in the hospital. In many cases, the surgeon will decide to use a laparoscopic approach instead.
A laparoscopic surgery is done through several small incisions instead of one big cut. This is considered a minimally invasive option. The specific laparoscopic procedure used to repair a hiatal hernia is called the Nissen fundoplication. This procedure creates a permanent solution to your hiatal hernia symptoms. During the procedure, your surgeon will make five or six tiny incisions in the abdomen. The laparoscope (a tool that allows the surgical team to see your internal organs on a screen in the operating room) and other surgical instruments are inserted through the small incisions. The fundus is wrapped around the esophagus and the sphincter is tightened during surgery. The advantages of laparoscopic surgery compared to an open surgery include:
- Smaller incisions.
- Less risk of infection.
- Less pain and scarring.
- A shorter recovery.
Outlook / Prognosis
How effective is surgery for a hiatal hernia?
A laparoscopic repair of hiatal hernia and reflux, called Nissen Fundoplication, is very effective in most patients. This surgery requires general anesthesia and a short stay in the hospital. If you need to have an open surgical procedure, the recovery time will be longer and you may need to stay in the hospital for several days. After surgery, most patients no longer require long-term treatment with prescription or over-the-counter antacid medications.
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