A hiatal hernia occurs when an internal body part pushes into an area where it doesn’t belong. Your diaphragm normally has a small opening (hiatus) through which your food tube (esophagus) passes on its way to connect to your stomach. The stomach can push up through this opening and cause a hiatal hernia. This condition mostly occurs in people who are over 50 years old. It affects up to 60 percent of people by the time they’re 60, according to the Esophageal Cancer Awareness Association (ECAA).
There are two main types of hiatal hernias:
- A sliding hiatal hernia, the junction of the stomach and the esophagus herniate (slide) up into the chest through the hiatus. This is the most common type of hiatal hernia.
- A Paraesophageal hernia is less common, but is more cause for concern. The esophagus and stomach stay in their normal locations, but part of the stomach squeezes through the hiatus, placing it next to the esophagus. Although you can have this type of hernia without any symptoms, the danger is that the stomach can become “strangled,” which means its blood supply is cut off.
Often, people with a hiatal hernia also have heartburn or gastroesophageal reflux disease (GERD). Although there is a link, one condition does not necessarily cause the other, because some people can have a hiatal hernia without having GERD, and vice versa.
The exact cause of many hiatal hernias isn’t known. In some people, muscle tissue may be weakened by injury or other damage. This makes it possible for your stomach to push through your diaphragm.
Another cause is putting too much pressure on the muscles around your stomach. This may happen when:
- straining during bowel movements
- lifting heavy objects
Some people are also born with an abnormally large hiatus. This makes it easier for the stomach to move through it.
Factors that can increase your risk of a hiatal hernia include:
Signs and Symptoms
Hiatal hernia has often been called the “great mimic” because its symptoms can resemble many disorders.
- Chest pain or pressure
- Difficulty swallowing
- Pain: At times, a hiatal hernia causes chest pain or upper abdominal pain when the stomach becomes trapped above the diaphragm through the narrow esophageal hiatus.
- Other causes: Rarely, with a fixed hiatal hernia, the blood supply is cut off to the trapped portion of the stomach, causing great pain and serious illness. This is called a strangulated hiatal hernia, and it is a true medical emergency.
Hiatal hernia also causes symptoms of discomfort when it is associated with a condition called gastroesophageal reflux disease, commonly called GERD. This condition is characterized by upwelling of stomach acids and digestive enzymes into the esophagus through a weakened sphincter that is supposed to act as a one-way valve between the esophagus and stomach. Hiatal hernia is thought to contribute to the weakening of this sphincter muscle.
Although it is true that hiatal hernia or GERD can cause chest pain similar to angina (or heart pain) including chest pressure that can radiate to the arm or neck, do not assume that such pain is caused by the less serious condition of the two. When in doubt, it is safer to be seen by a doctor immediately in order to rule out more serious problems first.
- Pulmonary (lung) aspiration
- Slow bleeding and iron deficiency anemia (due to a large hernia)
- Strangulation (closing off) of the hernia
Several tests can be done to diagnose a hiatal hernia.
- Barium X-Ray- Your doctor may have you drink a liquid with barium in it before taking an X-ray. This X-ray provides a clear silhouette of your upper digestive tract. The image allows your doctor to see the location of your stomach. If it is protruding through your diaphragm, you have a hiatal hernia.
- Endoscopy-Your doctor may slide a thin tube in your throat and pass it down to your esophagus and stomach. Your doctor will be able to see if your stomach is pushing through your diaphragm. Any strangulation or obstruction will also be visible.
Many people do not experience any symptoms related to their hiatal hernia, so no treatment is necessary.
When mild symptoms occur such as heartburn, bloating or stomach discomfort a hiatal hernia may be successfully treated by making these lifestyle changes:
- 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). If you take over-the-counter medications for longer than two weeks without any improvement, see your physician. Your physician may prescribe a stronger medication to manage your symptoms.
If the hiatal hernia is complicated by severe symptoms of GERD or if the symptoms and tests suggest that a paraesophageal hernia (part of the stomach squeezes through the hiatus) may be present, surgery may be recommended.
The surgical procedure used is called Nissen fundoplication. In fundoplication, the gastric fundus (upper part) of the stomach is wrapped, or plicated, around the inferior part of the esophagus, preventing herniation of the stomach through the hiatus in the diaphragm and the reflux of gastric acid. The procedure is now commonly performed laparoscopically. With proper patient selection, laparoscopic fundoplication has low complication rates and a quick recovery.
Lifestyle changes may help control the signs and symptoms of acid reflux caused by a hiatal hernia. Consider trying to:
- Eat several smaller meals throughout the day rather than a few large meals.
- Avoid foods that trigger heartburn, such as chocolate, onions, spicy foods, citrus fruits and tomato-based foods.
- Avoid alcohol.
- Eat at least two hours before bedtime.
- Lose weight if you’re overweight or obese.
- Stop smoking.
- Elevate the head of your bed 6 inches (about 15 centimeters)