Hiatal Hernia

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.

What causes a hiatal hernia?

The most common cause of a hiatal hernia is an increase in pressure in the abdominal cavity. (The abdomen consists of the lower part of the esophagus, stomach, small intestine, colon, rectum, liver, gallbladder, pancreas, spleen, kidneys, and bladder.) Pressure can come from coughing, vomiting, straining during a bowel movement, heavy lifting, or physical strain. Pregnancy, obesity, or extra fluid in the abdomen can also lead to a hiatal hernia.

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 age 50 and older. Hiatal hernia occurs more often in overweight people, and smokers.

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 a gastroesophageal reflex disease (GERD). GERD occurs when digestive juices move from the stomach back into the esophagus. Symptoms of GERD include:

• Heartburn
• 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 doctor or go to the emergency room if you experience any chest pain.

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 examined with an endoscope (a long, thin, flexible instrument about 1.27 centimeters (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 nausea and vomiting besides a hiatal hernia.

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:

• Losing weight, if overweight.
• Decreasing the size portions 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 containing caffeine (including chocolate), peppermint, carbonated beverages, alcoholic beverages, ketchup and mustard, and vinegar.
• Eating meals at least 3 to 4 hours before lying down, and avoiding bedtime snacks.
• Keeping your head 15 centimeters (6 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.
• 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 H2 blockers (such as Pepcid AC® or Zantac®).

Note: If you take over-the-counter medications for longer than 2 weeks without any improvement, see your physician. He or she can prescribe stronger medications such as pantoprazole (Protonix®), rabeprazole (Aciphex®), esomeprazole (Nexium®), omeprazole (Prilosec®), lansoprazole (Prevacid®), or others.

When is surgery for 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, surgery is needed. Surgery may also be needed in people with a hiatal hernia who also 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. The valve prevents stomach contents from backing up into the 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 hiatal hernia performed?

Surgery involves pulling the hiatal hernia back into the abdomen and creating an improved valve mechanism at the bottom of the esophagus and closing the hole in the diaphragm muscle. 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 stomach contents will not reflux back into the esophagus.

Two approaches to surgery can be performed. One is an open procedure. This surgery is performed through long incisions. The second procedure is a minimally invasive procedure. This is performed 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 is guided by the laparoscope, which transmits a picture of the internal organs on a monitor. The advantages of laparoscopic surgery compared with an open surgery include smaller incisions, less risk of infection, less pain and scarring, and a more rapid recovery.

How effective is surgery for hiatal hernia?

A laparoscopic repair of hiatal hernia and reflux, called Nissen Fundoplication, is about 90 percent effective in most patients. This surgery requires general anesthesia and a one day stay in the hospital. After surgery, most patients no longer require long-term treatment with prescription or over-the-counter antacid medications.