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Last Updated: October 19, 2017

Hiatal Hernia

Overview

Hiatal hernia is a condition in which part of the stomach bulges up above the diaphragm into the chest cavity. Normally, the esophagus is positioned in the chest and the stomach is in the abdomen. A small opening (hiatus) in the diaphragm allows the esophagus to pass through to the stomach. Weakness of the diaphragm muscles adjacent to the hiatus allows the stomach to protrude through the hiatus into the chest.

A hiatal hernia may weaken the lower esophageal sphincter (LES), the important barrier muscle between the esophagus and stomach, which prevents food and stomach acids from backing up into the esophagus. A weak LES results in a backward flow of stomach contents (acid reflux), causing irritation and inflammation of the lining of the esophagus, a condition known as gastroesophageal reflux disease (GERD).

Types of hiatal hernias:

  1. Sliding. During periods of increased abdominal pressure, a portion of the stomach slides up above the diaphragm. When the pressure decreases, the stomach returns to its normal position.
  2. Fixed (paraesophageal). At least a portion of the stomach remains in the chest cavity at all times. This form causes more severe symptoms than the sliding type.

The incidence of hiatal hernia increases with age. Most people experiencing this condition are over age 50 and obese.

Causes

Increased pressure within the abdomen is the main risk factor for this condition.

Esophageal hiatus illustration, inferior view

The following factors contribute to development of a hiatal hernia:

Symptoms

Most individuals with small hiatal hernias do not experience any symptoms at all. However, large hiatal hernias cause a variety of symptoms related to gastroesophageal reflux. These include:

Severe acid reflux can lead to the following complications:

Diagnosis

Chest pain (heartburn), a common symptom of hiatal hernia and GERD, is difficult to distinguish from the symptoms of heart disease. Therefore, initial tests are often directed at ruling out heart problems.

An evaluation of the esophagus and stomach includes the following procedures:

Treatment

Lifestyle and activity modifications include the following:

Recommended dietary changes include:

Medications to treat GERD (available over-the-counter and by prescription) include:

Surgery is sometimes necessary to repair large fixed (paraesophageal) hiatal hernias when symptoms are uncontrolled with medications. The procedure involves pulling the stomach back down into its normal position, below the diaphragm, and tightening the esophageal hiatus. Various approaches to the surgery include an incision in the chest (thoracotomy), an incision in the abdomen (laparotomy), or tiny incisions in the abdomen through which a small camera and long narrow instruments are inserted (laparoscopy).

Prevention

Important measures to prevent hiatal hernia include maintaining a healthy body weight and not smoking. Individuals are generally advised to exercise but avoid excessive heavy lifting, straining, and slouching. Avoiding those foods that trigger acid reflux can prevent GERD symptoms and complications.

Sources

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Carla Hightower, MD

Dr. Hightower is an experienced physician who studied medicine at Northwestern University, where she also earned an MBA. As the founder of Living Health Works, she offers health coaching to individuals, private groups and corporations.