Five facts you should know about hiatal hernias

As a medical professional and board-certified thoracic surgeon, I understand there is lot of information out there about common medical conditions that individuals deal with on a daily basis – including hiatal hernias.

A hiatal hernia occurs when part of the stomach pushes up into the diaphragm through an opening called the esophageal hiatus, through which the esophagus travels to bring food to the stomach. Most of the time, symptoms of reflux from hiatal hernias may be treatable with medication. Some require surgery.

Since it’s not always easy to find and identify what is relevant and reliable information about this condition, here are five facts you should know.

Fact 1: Hiatal hernias, especially smaller ones, are relatively common. Statistics reveal that 60% of adults will have some degree of a hiatal hernia by age 60, and even these numbers do not reflect the real prevalence of the condition because many hiatal hernias can be asymptomatic. You could be walking around with a hiatal hernia and not know it.

For some people, the hernia will never cause any problems. For others, it can cause painful symptoms over time, and the individual will need to seek medical treatment.

Fact 2: Symptoms of hiatal hernias can be variable, ranging from nothing unusual to trouble swallowing and reflux disease. Sometimes, people with a hiatal hernia may find themselves gravitating towards smaller meals and feeling full very quickly. Other times, people experience shortness of breath or discomfort/pain around the diaphragm and into the belly.

Hiatal hernias often mask as different conditions. Sometimes, people with large hiatal hernias present with very low iron levels (anemia). The underlying cause for this is thought to be small erosions at the base of the hernia that cause a leakage of blood, although there are other factors as well. Hiatal hernias also mask as heart problems and many will go see a doctor complaining of chest pain and severe heartburn.

Fact 3: There is a genetic factor. As a thoracic surgeon who has operated on many patients with hiatal hernias, I can tell you that a person can be predisposed to getting hernias in general, including hiatal hernias. The reason for this is that hernias are more likely to occur in people with looser connective tissues or an unusually large hiatus.

If a parent has this type of tissue, their children often do as well. Lifestyle factors like obesity, smoking, and age can increase the chance that a hernia will form. Some hernias can take several years to develop.

Fact 4: Hiatal hernias can be treated with minimally invasive surgery using tiny incisions, resulting in less blood loss and scarring, leading to an easier, faster recovery. Minimally invasive surgery performed for a hiatal hernia can reduce the likelihood of later complications such as an abdominal wall hernia, which can form when longer, open incisions are used. However, if the hernia is large, with multiple organs affected, then an open surgery might be necessary.

Fact 5: Your surgeon matters. Go to an experienced surgeon and surgery center to get the best hiatal hernia repair. He or she will know certain techniques that can help prevent recurrence of the hiatal hernia and/or the likelihood of the formation of an abdominal wall hernia.

Most of the time, hiatal hernias are not considered a medical emergency. However, if the hernia becomes strangulated, meaning there is a lack of blood flow to tissue that has moved up through the diaphragm, then it is imperative that it be corrected immediately to prevent necrosis (tissue death) or perforation of the stomach (a hole in the stomach tissue).

Additional Resources

Learn more about the Division of General Thoracic Surgery at Baylor College of Medicine.

See more information about hiatal hernias.

-By Dr. Philip Carrott, assistant professor of surgery in the Michael E. DeBakey Department of Surgery at Baylor College of Medicine

Hiatus hernia – Illnesses & conditions

Treatment for a hiatus hernia is usually only necessary if it’s causing problems.

In most cases, people with a hiatus hernia only experience problems if the hernia causes gastro-oesophageal reflux disease (GORD). GORD can cause symptoms such as heartburn and an unpleasant taste in your mouth.

Lifestyle changes and medication are the preferred treatments, although surgery may be used as an alternative to long-term medication, or if other treatments are ineffective.

Lifestyle changes

There are several things you can do yourself to help relieve symptoms of GORD caused by a hiatus hernia. These include:

• eating smaller, more frequent meals, rather than three large meals a day
• avoiding lying down (including going to bed) for at least 3 hours after eating or drinking
• avoiding drinking during the night
• removing certain foods from your diet if you think they make your symptoms worse
• avoiding alcohol, caffeine, chocolate, tomatoes, fatty foods, spicy foods and acidic food or drinks, such as citrus fruit juice, if they make your symptoms worse
• avoiding bending over or stooping, particularly after eating or drinking
• raising the head of your bed by around 20cm (8 inches) by placing a piece of wood or blocks under it; don’t use extra pillows, because this may increase pressure on your abdomen

If you’re overweight, losing weight may help to reduce the severity and frequency of your symptoms.

If you smoke, you should try to give up. Tobacco smoke can irritate your digestive system and may make your symptoms worse.

Read about stopping smoking.

Medication

A number of different medications can be used to treat symptoms of hiatus hernia. These are described below.

Antacids

Antacid medicines can relieve some of the symptoms of hiatus hernia. They come in liquid or tablet form and can be swallowed or chewed. They help to neutralise stomach acid when they reach the oesophagus and stomach by making it less acidic.

However, antacid medicines don’t work for everyone. They’re not a long-term solution if symptoms persist or you’re in extreme discomfort.

Antacids shouldn’t be taken at the same time as other medicines, because they can stop other medicines from being properly absorbed by your body. They may also damage the special coating on some types of tablets. Ask your GP or pharmacist for advice.

Alginates

Alginates are an alternative medicine to antacids. They work by producing a protective coating that shields the lining of your stomach and oesophagus from the effects of stomach acid.

h3-receptor antagonists

In some cases, a medicine known as an h3-receptor antagonist (h3RA) may be recommended if a hiatus hernia is causing GORD. Examples of h3RAs include cimetidine, famotidine (PepcidTwo) and ranitidine.

h3RAs block the effects of the chemical histamine, which your body uses to produce stomach acid. h3RAs therefore help to reduce the amount of acid in your stomach.

Side effects of h3RAs are uncommon. However, possible side effects may include diarrhoea, headaches, tiredness and a rash.

Some h3RAs are available over the counter at pharmacies. These types of HR2As are taken in a lower dosage than the ones available on prescription. Ask your GP or pharmacist if you’re not sure whether these medicines are suitable for you.

Proton-pump inhibitors (PPIs)

Your GP may prescribe a medication called a proton-pump inhibitor (PPI). PPIs work by reducing the amount of acid produced by your stomach. Examples of the PPIs you may be prescribed include omeprazole, lansoprazole, rabeprazole and esomeprazole.

Most people tolerate PPIs well and side effects are uncommon. When they do occur, they’re usually mild and can include headaches, diarrhoea, feeling sick or constipation.

To minimise any side effects, your GP will prescribe the lowest possible dose of PPIs they think will be effective. You should let your GP know if the prescribed dose of PPIs doesn’t work. A stronger dose may be needed. 

Surgery

Surgery is usually only recommended for a sliding hiatus hernia (hernias that move up and down, in and out of the chest area) if the problem fails to respond to lifestyle changes and medication.

You may also want to consider surgery if you have persistent and troublesome symptoms, but don’t want to take medication on a long-term basis.

Prior to surgery, you may need further investigations to check how well the oesophagus moves (manometry) and how much acid is being refluxed (24-hour oesopageal pH studies).

Laparoscopic nissen fundoplication (LNF)

A procedure called a laparoscopic nissen fundoplication (LNF) is one of the most common surgical techniques used to treat GORD and sliding hiatus hernias.

LNF is a type of keyhole surgery that involves making a series of small cuts in your abdomen. Carbon dioxide gas is used to inflate your abdomen to give the surgeon room to work in.

During LNF, the stomach is put back into the correct position and the diaphragm around the lower part of the oesophagus is tightened. This should prevent any acid moving back out of your stomach.

LNF is carried out under general anaesthetic, so you won’t feel any pain or discomfort. The surgery takes 60 to 90 minutes to complete.

After having LNF, you should be able to leave hospital after you’ve recovered from the effects of the general anaesthetic. This is usually within 2 to 3 days. Depending on the type of job you do, you should be able to return to work within 3 to 6 weeks.

For the first 6 weeks after surgery, it’s recommended that you only eat soft food, such as mince, mashed potatoes or soup. Avoid eating hard food that could get stuck at the site of the surgery, such as toast, chicken or steak.

Common side effects of LNF include difficulties swallowing (dysphagia), belching, bloating and flatulence.

These side effects should resolve over the course of a few months. However, in about 1 in 100 cases they can be persistent. In such circumstances, further corrective surgery may be required.

Para-oesophageal hiatus hernia

If you have a para-oesophageal hiatus hernia, where the stomach pushes up through the hole in the diaphragm next to the oesophagus, surgery may be recommended to reduce the risk of the hernia becoming strangulated (see complications of a hiatus hernia for more information).

Hiatus hernia – HH symptoms and treatment

Table of contents

Hiatus hernia affects several organs in aggregate. The esophagus passes into the epigastrium through the hiatal opening in the diaphragm, and hiatal hernia occurs when part of the stomach is forced into the chest cavity. The most vulnerable are considered to be pregnant women, people over 50 and obese. Also, a hernia of the esophageal opening of the diaphragm can be caused by excessive strength exercises, lifting heavy loads, excessive stress during bowel movements, etc. Hiatal hernia of the diaphragm is predominantly an acquired disease, but hereditary cases are also observed. With the manifestation of relevant symptoms and the identification of HH, a decision is made to perform an operation to remove the hernia. In some cases, you can try to do conservative treatment without surgery, but this method is not applicable to all types of HH and only temporarily relieves the symptoms of the disease.

Varieties of HH

Hiatal hernia is classified based on the specifics of displacement and two key types are distinguished in its typology: treatment in a hospital.

paraesophageal hiatal hernia is the most dangerous case for health, causing serious complications and disrupting blood flow to vital organs.

In addition, there are several stages of severity of the course of the disease (stages I, II, III and IV) based on the degree of transition of the stomach into the sternal region.

Factors affecting the development of HH

HH develops due to a pathological change in the size of the esophageal opening. With minor deviations from the permissible values, a hernia of the esophageal opening of the diaphragm does not show symptoms until a targeted diagnosis, and the signs of HH are easily confused with manifestations of other diseases of the gastrointestinal tract or from the cardiovascular system.

Hernia of the alimentary opening of the diaphragm can manifest itself due to many circumstances and is currently increasingly common in medical practice.

Main factors in the development of HH:

• muscle hypotension due to age;
• chronic diseases of the gastrointestinal tract;
• intra-abdominal hypertension;
• weight fluctuation;
• complications from operations on the esophagus;
• a consequence of trauma to the abdomen.

As for the complications that hiatal hernia can provoke, the most common is reflux esophagitis. The obvious symptoms of reflux esophagitis include regular bouts of heartburn after eating. Usually this complication is inherent if the patient has a sliding (axial) hiatal hernia, and as a treatment, the patient is prescribed therapy that normalizes acidity. Erosions of the esophagus and stomach are also quite often manifested, which in turn, if not detected and treated in time, can lead to a precancerous state of latent gastrointestinal bleeding and, as a result, cause anemia. Moreover, hiatal hernia can lead to peritonitis and sepsis due to compression of the hernia. With obvious symptoms of intoxication, vomiting, acute persistent pain, hospitalization is indicated as soon as possible.

Hiatal hernia is more often asymptomatic, but at the same time has a number of symptoms that may indicate the presence of the disease.

Symptoms of HH

Often HH is so small that it is hidden, but in more severe cases the following symptoms occur:

• frequent heartburn;
• belching;
• hiccups;
• difficulty and discomfort in swallowing;
• extremely fast satiety;
• sharp pains in chest;
• sore tongue;
• attacks of dry cough.

As practice shows, a patient with a confirmed diagnosis of hiatal hernia usually suffers immediately from a number of symptoms and needs treatment based on the diagnosed type of HH.

For correct treatment it is necessary to carry out a complete diagnosis, taking into account the most detailed questioning of the patient for the presence of symptoms, data on acidity and indicators of hernia. Hiatus hernia is detected by contrast radiography, esophageal motility studies, gastroscopy with biopsy, and daily pH-metry.

Outpatient treatment of HH

Treatment of HH begins with conservative methods, if the severity of the symptoms and the severity of the course of the disease allow. Since a hernia of the esophageal opening of the diaphragm can proceed in a latent form for a long time and with a high degree of probability the patient has already taken certain actions to alleviate his condition, first of all, they conduct detailed consultations with a gastroenterologist to determine the correct treatment tactics. There are general rules, following which you can significantly improve the quality of life:

• adhere to the fractional diet plan;
• limit the consumption of certain foods that cause heartburn and adversely affect the digestive tract;
• do not lie down for 3 hours after eating;
• stop drinking alcohol and smoking.

It should be added that conservative treatment implies only relief of symptoms of reflux esophagitis and is effective only at the initial stage of HH.

Surgical treatment of HH

If negative dynamics persist, doctors may decide that surgery is necessary. This is a more radical way of treatment, but also more effective, especially in case of acute exacerbations of the disease and if the hiatal hernia has developed into stages III and IV. Often, a hernia of the esophageal opening of the diaphragm can be accompanied by a number of other diseases of the gastrointestinal tract, therefore, in such cases, complex treatment is performed. Today, surgeons prefer laparoscopic operations due to their low trauma and reduced time for postoperative recovery.

Since a hernia of the esophageal opening of the diaphragm significantly disrupts the normal arrangement and functioning of several organs of the abdominal and sternal regions, the operation to eliminate it consists in performing a number of established manipulations:

Fundoplication, as a rule, is performed by the following methods:

• the author’s method of Academician A.F. Chernousov, the founder of antireflux surgery in Russia; This is a laparoscopic fundoplication, due to which a lasting effect is achieved with a recurrence probability of only 2% within a year from the moment of operation.
• Nissen fundoplication involves the formation of a cuff around the esophagus to maintain the correct functioning of its lower sphincter. This is a classic operation used to treat HH, but it has several disadvantages. For example, the lower esophageal sphincter is blocked not only for gastric juice, but also for the release of gases, which provokes bloating. In some cases, there is a relapse of the disease.
• The Tope fundoplication differs from the Nissen method in the degree of fundus turnover (270 degrees) and, most importantly, in the complete preservation of the function of the lower esophageal sphincter.

Dietary restriction and rest for about three weeks is the key to a successful and quick recovery. In most cases, if the hernia of the esophageal opening of the diaphragm is removed in a timely manner and the treatment was carried out taking into account all the recommendations, the patient will be guaranteed to be able to return to his usual way of life.

Branches and departments that treat hiatal hernia

Diaphragmatic hernia – symptoms, methods of diagnosis and treatment

Author

Samokhvalova Nina Igorevna

Leading physician 9 0003

Gastroenterologist

Creation date: 2020. 05.19

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Diaphragmatic hernia

Hiatus hernia (diaphragmatic hernia) occurs if through the esophageal opening of the diaphragm – the hole through which the esophagus from the chest cavity penetrates into the abdominal – the abdominal part of the esophagus, part of the stomach or the abdominal part of the esophagus, together with part of the stomach, is displaced into the chest cavity. Sometimes other organs located in the abdominal cavity can also be displaced through the esophageal opening of the diaphragm into the chest cavity.

At the beginning of the disease, the displacement of the organs of the abdominal cavity into the chest cavity occurs periodically, under the influence of physical exertion, coughing, vomiting, overeating, etc. Then such a loss becomes more frequent or permanent. The most common hernia is axial or sliding. In this case, the abdominal part of the esophagus or the final section of the esophagus with part of the stomach falls into the esophageal opening of the diaphragm.

A complication of a hernia of the esophageal opening of the diaphragm is most often reflux esophagitis, but a peptic ulcer of the esophagus may develop, with a long course of which, in turn, cicatricial stenosis (narrowing) of the esophagus may occur. There are acute and chronic bleeding from the esophagus, perforation of the esophagus, or strangulated hernia in the esophageal opening of the diaphragm.

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Diaphragmatic hernia causes

The cause of diaphragmatic hernia is the increased elasticity of the tissues that limit the esophageal opening of the diaphragm. Such elasticity may be innate. Sometimes there is an anomaly of development – the so-called “short esophagus with a thoracic stomach.” But more often a hernia occurs during the patient’s life under the influence of conditions that contribute to an increase in intra-abdominal pressure: heavy physical labor, obesity, ascites (accumulation of fluid in the abdominal cavity), endocrine diseases. Sometimes pregnancy leads to a hiatal hernia. The weakening and thinning of ligaments and connective tissue with age matters.

Diaphragmatic hernia symptoms

One of the most common complaints is heartburn (due to reflux of stomach contents into the esophagus).

Pain in hiatal hernia occurs in 40-50% of patients. The pain is quite intense, felt retrosternally, has a burning character and, therefore, is often confused by patients with pain in angina pectoris. Pain with a hernia of the esophagus is most often associated with bending, physical activity and is aggravated by lying down. With a change in body position, the pain often subsides.

Difficulty in the passage of food through the esophagus with a hernia of the esophageal opening of the diaphragm is intermittent. It is often provoked by the intake of very cold or, on the contrary, very hot food, as well as nervous overload. The persistent nature of the difficulty in passing food through the esophagus should be alert for complications.

Heartburn

With a hernia of the diaphragm, heartburn often occurs at night or after eating. Heartburn can also occur after exercise, and is often accompanied by pain.

More about the symptom

Belching

Another common symptom of hiatal hernia is belching. Belching – involuntary sudden release of gases through the mouth from the stomach or esophagus, sometimes with an admixture of stomach contents, occurs in 30 – 73% of patients. Belching occurs with gastric contents or air. Belching is usually preceded by a feeling of fullness in the epigastric region. This condition occurs after eating or during a conversation. Taking antispasmodics is ineffective, only belching a significant amount of food brings relief.

More about the symptom

Diagnostic methods for diaphragmatic hernia

Diagnosis of hernia of the esophageal opening of the diaphragm is established by x-ray examination. Conventional fluoroscopy of the esophagus and stomach with barium contrast is often sufficient.