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 viewThe following factors contribute to development of a hiatal hernia:

  • Obesity
  • Coughing
  • Straining with bowel movements
  • Heavy lifting
  • Vomiting
  • Traumatic injury to the diaphragm
  • Smoking.

 

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:

  • Chest pain (heartburn)
  • Upper abdominal pain
  • Coughing
  • Belching
  • Difficulty swallowing.

Severe acid reflux can lead to the following complications:

  • Esophageal inflammation (esophagitis)
  • Narrowing of the esophagus (esophageal stricture)
  • Precancerous changes in the lining of the esophagus (Barrett’s esophagus) and an increased risk of developing esophageal cancer.

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:

  • Upper gastrointestinal series (barium swallow). A procedure in which the patient swallows liquid contrast material, visible with an x-ray, that provides an image of the esophagus and stomach to detect abnormalities such as hiatal hernia.
  • Upper endoscopy. A long flexible instrument with a video camera is passed through the mouth into the esophagus and stomach to inspect the tissues for evidence of complications from acid reflux and GERD.

Treatment

Lifestyle and activity modifications include the following:

  • Lose weight
  • Quit smoking
  • Avoid heavy lifting
  • Avoid bending over
  • Improve posture
  • Elevate the head of the bed 4 to 6 inches
  • Exercise.

Recommended dietary changes include:

  • Eat small meals more frequently instead of large meals
  • Avoid eating within 2 to 3 hours of bedtime
  • Avoid foods that worsen GERD symptoms, such as caffeine, chocolate, citrus fruit, tomato sauce, fried or fatty foods, alcohol, and peppermint.

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

  • Antacids to relieve heartburn and GERD symptoms by neutralizing stomach acids.
  • H-2 (histamine) receptor blockers to decrease the production of stomach acid.
  • Proton pump inhibitors, which are highly effective for GERD treatment. These medications block stomach acid production, allowing more time for the esophagus to heal.

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

  • Hiatal Hernia. Mayo Clinic website. http://www.mayoclinic.org/diseases-conditions/hiatal-hernia/basics/definition/con-20030640. Accessed November 12, 2014.
  • Gastroesophageal Reflux (GER) and Gastroesophageal Reflux Disease (GERD) in Adults. National Digestive Diseases Information Clearinghouse (NDDIC), National Institute of Health website. http://digestive.niddk.nih.gov/ddiseases/pubs/gerd/index.aspx. Accessed November 12, 2014.
  • GERD, Hiatal Hernia, and Surgery. International Foundation for Functional Gastrointestinal Disorders (IFFGD) website. http://www.aboutgerd.org/site/treatment/surgery/gerd-hiatal-surgery. Accessed November 13, 2014.
  • Kahrilas PJ, Hirano I. Chapter 292. Diseases of the Esophagus. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson J, Loscalzo J. eds. Harrison's Principles of Internal Medicine, 18e. New York, NY: McGraw-Hill; 2012.