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 where hiatal hernia is treated

Esophageal hernia treatment methods | სამედიცინო პორტალი VIPMED.

GE

Recently, esophageal hernia is one of the most common pathologies, but many do not know what this disease means and what complications may follow if it is left unattended.

There are various causes of esophageal hernia, although it is often confused with other conditions based on symptoms. What is meant by hiatal hernia? What causes an esophageal hernia? What methods of treatment exist in modern medicine for hernia of the esophagus? – General and minimally invasive surgeon, academic doctor of medicine Mr. David Elgandashvili talks about this and other important issues.

– Mr. David, what is meant by hiatal hernia?

– The diaphragm is a muscle-tendon organ that separates the chest from the abdominal cavity, it has natural openings through which the organs located in the chest fall into the abdominal cavity, including the esophagus. There is a special sphincter that provides isolation of the esophagus from the stomach, taking into account the fact that there is an alkaline environment in the esophagus, and an acidic one in the stomach. Therefore, when swallowing, the lump reflexively enters the oral cavity, the sphincter opens and the lump enters the stomach with the help of the muscles of the esophagus. The specified sphincter must be closed, isolation from the stomach must occur so that gastric juice, hydrochloric acid and gases and liquids harmful to the esophagus are not released into the esophagus.

When the muscles of the diaphragm weaken and this opening expands, the internal pressure in the abdominal cavity is higher than the pressure in the chest cavity. Therefore, the migration of the abdominal organs is carried out to the esophagus. The stomach enters this hole first, the hole widens and widens, migration occurs from the level of the diaphragm of the lower sphincter to the chest cavity. And this violates the force of contraction of the muscles of the diaphragm, the sphincter opens relatively easily, does not close completely, and the contents of the stomach return to the esophagus. The larger this hole, the higher the discharge of contents occurs, almost to the neck area, sometimes aspiration of gastric juice occurs, gastric juice can also enter the lungs and cause unnatural complaints.

– What causes esophageal hernia?

– As I have already noted, the diaphragm is a muscular organ, the very first thing that affects it is mechanical factors that imply an increase in the internal pressure of the abdominal cavity. An increase in the internal pressure of the abdominal cavity depends on many factors, for example, from physical activity, excess weight, pregnancy, sometimes we can deal with a congenital muscle defect, the muscle layer can be so thin that even a small load can further complicate the problem. This pathology is an occupational disease for persons working on wind instruments. In general, a hernia of the esophagus is not expressed with great complaints, its main complaint is heartburn, which a person can have without a hernia as a result of excessive eating, carbonated drinks, alcohol, therefore, this problem is often not paid attention to. The patient only then goes to the doctor if belching, bloating, pain and discomfort are added to the disease. During gastroscopy, swallowing the probe, the stomach swells. In this case, provoking a hernia of the esophagus is common. Therefore, only as a result of gastroscopy, we cannot say that a hiatal hernia is developed.

– For people who play sports, is it necessary to conduct regular examinations in terms of esophageal hernia?

– Sports load is carried out under the supervision of a coach, he indicates how the training schedule should be carried out. Therefore, this problem is rare in athletes. From this disease, those who arbitrarily start training are more likely to suffer. In this case, an incarcerated hernia may also occur, which suggests that the stomach jumps into a narrow opening and the muscles of the diaphragm act on the stomach. And this will cause a violation of the blood supply and in some cases – complications.

– Can the symptoms of this disease be similar to other diseases, and the patient goes to the wrong doctor?

– This disease has many non-specific complaints. Heartburn can develop as a result of a process caused in the stomach, due to an ulcer in the stomach, there may be pain, aspiration of the contents occurs and constant irritation of the lungs. Such patients are treated for a long time with antibiotics, anti-inflammatory drugs by pulmonologists, although the treatment is ineffective and, in the end, patients come to us for surgical intervention. Based on such symptoms, frequent referral to an ear-nose-throat specialist. Experienced doctors are faced with a different genesis of this disease and patients are referred to a surgeon or gastroenterologist.

Hiatus hernia is confused with cardiac patients and is sometimes treated inappropriately.

Unfortunately, Georgian patients do not fully search for the causes of the disease.

– Is there an age limit in case of esophageal hernia?

– Hernia of the esophagus at a young age is mainly caused by a congenital defect of the diaphragm. In this case, surgical intervention is necessary.

As for adulthood, according to world data, it is described that this pathology develops more often in people over 50 years old, but this statistic was caused by an incorrect diagnosis. As a result of the development of diagnostics and increased negotiability, we often encounter esophageal hernia at a young age. In the elderly, esophageal hernia is mainly caused by relaxation of the diaphragm. The disease affects mainly the mature, physically active segment of the population, and this significantly changes the way of life of people.

– In infancy, how can a parent guess that the baby suffers from a hernia of the esophagus?

– When a hernia of the esophagus occurs, the newborn cries constantly and experiences discomfort. In this case, the disease is detected radiologically by taking barium porridge. In kindergarten or preschool age, a hernia of the esophagus develops to a lesser extent.

– What types of esophageal hernia exist and which are the most common?

– There are different classifications of esophageal hernia. Back in the XVII-XVIII centuries, they suspected the entrance of the stomach into the diaphragm. Since this period, several classifications have been formulated. According to recent data, there are two types of hernia: a hernia of the mobile esophagus (axial) – a hernia that moves up and down in the chest cavity and a hernia of the paraesophageal esophagus – at this time the stomach rises into the opening of the diaphragm where the esophagus passes. There are also mixed forms.

– Which form of hernia is the most dangerous?

– In terms of complaints, creeping, axial hernia is more dangerous than paraesophageal hernia, since this form damages the esophageal sphincter the most. In another case, the release of gastric tissue occurs mainly in the mediastinum. The impact on the stomach of the contractile muscle of the diaphragm is dangerous, as this will cause malnutrition and necrosis of the stomach.

– Mr. David, let’s talk about research and diagnostic methods.

– X-ray is preferred for the first examination. Swallowing a tube or gastroscopic treatment requires mechanical inflation and distension of the stomach in order for visualization of the mucosa to occur. At the first stage, it is better to use an X-ray, on the X-ray physiologically there is no bloating of the stomach. A person swallows barium porridge, which is clearly visible on the X-ray; in direct mode, swallowing and viewing the food portion takes place. We see how the contrast agent enters the stomach. At this time polypositional research is necessary. In the case of this study, the device must be turned 360 degrees and the patient must stand in a horizontal position in order for the pressure to increase. The radiologist gives the patient an extra portion of barium porridge to drink. If during coughing and distension of the abdomen there was an outflow of this contrast, then the radiologist will catch the moment when a portion is ejected from the stomach into the esophagus. The polypositional rotation of the patient is clearly visible on x-ray. If we see a hernia on an x-ray, then this means that a hernia is developed.

A modern research method is 24-hour PH monitoring, which in Georgia exists only in our clinic and was acquired with the help of close foreign colleagues.

As far as research is concerned, there is a tube with the thinnest silicone wire that is swallowed from the nose, with jelly applied topically. It has eight sensors. It extends along the entire length of the esophagus and the last point is located at the entrance to the stomach, where the sphincter is located. The wire itself transmits information to the recording equipment, which encrypts at what level the acidity of the stomach rises in the esophagus and how much purification occurs. The esophagus physiologically has the ability to clear the acidic environment of the stomach. With a high frequency, the esophagus cannot cope with this process on its own and its mucous membrane is damaged. Finally, this process can develop into a tumor process.

Recording of the specified data must occur within 24 hours. The patient comes to us in the morning, a probe is inserted into him and the patient is sent home along with the indicated device. The next day, he comes to us again, the data is recorded on a special chip, then we decrypt the data in a computer program. The conclusion is made on the basis of these data.

The study costs approximately 600 GEL, but unfortunately, at this stage, the specified study does not have state funding.

– What methods of treatment are available in the modern world in case of hernia of the esophagus?

– In the case of a hernia of the esophagus, the patient may feel well after many years of treatment. He has the right to choose whether to prefer to be treated or to have an operation, but sometimes we are dealing with such a case when the operation is simply inevitable.

The operation of a hernia of the esophagus was first performed by Niessen in the fifties, but the operation at that time was done by an open method. In the 1990s, operations began to be carried out using the laparoscopic method.

Hernia surgery has been performed in Georgia since 2004. 5 small holes enter the abdominal cavity, the stomach is inflated with carbon dioxide and the image is displayed on the screen with a videoscope. At this time, we go deep and stitching the posterior opening of the esophagus so that the stomach does not migrate into the mediastinum.

The patient stays in the clinic for 2 days. The rehabilitation process is very simple, it is necessary to follow a two-three-week diet, heavy physical activity and carbonated drinks are not allowed.

Surgery for a hernia of the esophageal opening is indeed not a simple matter for a surgeon, but in case of a direct indication, for example, a large defect, the operation is effective. Therefore, research before surgery is mandatory. The later the patient turns to the doctor, the deeper will be the damage to the esophagus by the action of gastric juice.