An Overview of Hiatal Hernia

Common Causes and Current Treatment Strategies

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A hiatal hernia occurs when the upper part of your stomach bulges through the diaphragm—the muscle that separates the chest and abdomen. On the diaphragm is a small opening, called the hiatus, through which your feeding tube (esophagus) passes. If the stomach presses through this opening, it can cause food and acids to leak back into the esophagus, triggering heartburn, indigestion, and pain. While over-the-counter (OTC) and prescription medication, including antacids and acid-blockers, can treat related gastrointestinal symptoms, weight loss and diet changes are needed to reduce reflux all together.

 Surgery may be needed in severe cases.

Symptoms

More than half of the people diagnosed with a hiatal hernia will experience no symptoms at all. For those who do, reflux of gastric acid or air into the esophagus will be the main reasons why. The symptoms can vary significantly by the type of hernia you have.

A sliding hiatal hernia is a type in which the junction of the esophagus and stomach (referred to as the gastroesophageal junction) and part of the stomach protrude into the chest cavity. Hernias like these are called "sliding" because the herniated part of the stomach can slide back and forth in the cavity as you swallow.

Most small sliding hernias will not cause any symptoms. If symptoms do appear, they usually include:

  • Heartburn
  • Indigestion
  • Regurgitation
  • Belching
  • Hiccupping
  • Nausea and vomiting

A paraesophageal hernia is a less common but more serious type in which only the stomach pushes into the chest cavity.

Hernias like these can often cause food to get stuck in the esophagus or become twisted, cutting off the blood supply.

With that being said, most paraesophageal hernias will not cause symptoms if they are small. If they get bigger and begin to compress the esophagus, they can cause food to get stuck mid-chest as you try to swallow.

If the herniation bulges even further into the chest cavity, it can cause become trapped (incarcerated) in the hiatus and lead to:

  • Chest pain after eating
  • Upper abdominal pain and distention
  • Sharp chest pain that can't be treated with antacids
  • Difficulty swallowing (dysphagia)
  • Shortness of breath (dyspnea)
  • Inability to belch
  • Vomiting progressing to nonproductive retching
  • Black or tarry stools
  • Vomiting of blood

All of these are signs of an incarcerated hiatal hernia, a condition which can lead to the strangulation of the blood supply and gastric perforation. An incarcerated hernia should always be considered a medical emergency in need of immediate treatment.

Causes

The cause of a hiatal hernia is not always entirely clear. It may be that you were born with an unusually large hiatus or that age, surgery, or a physical injury has weakened the integrity of your diaphragm muscles.

Conditions like these can predispose you to a hiatal hernia, especially if you exert sudden or excessive pressure on the muscles around the stomach. Examples of this may include a chronic cough, lifting heavy objects, violent vomiting, or straining during a bowel movement.

Obesity is also a major contributing factor. People who are either overweight or obese have greater intra-abdominal pressure compared to those of healthy weight.

This pressure weakens the diaphragm muscles while expanding the hiatal space. As result, people considered obese—defined as a body mass index (BMI) greater than 30—are twice as likely to have a hiatal hernia than those with a BMI of less than 25.

The same can occur during pregnancy, usually in the later stages as the enlargement of the uterus exerts pressure on the abdominal wall.

Hiatal hernias tend to affect people over 50. While smoking does not cause a hiatal hernia, it can exacerbate symptoms by relaxing the lower esophageal sphincter (LES) meant to keep food and acid out of the esophagus.

Diagnosis

There are a number of common tests used to diagnose a hiatal hernia. The choice that's right for you is largely dependent on the type and severity of symptoms you are experiencing.

Among the most common diagnostic tools:

  • Barium X-rays are the tests most frequently used to diagnosis a hiatal hernia. Also referred to as a barium swallow, it requires you to drink a chalky fluid that coats the walls of your esophagus and stomach. This helps better isolate the organs on X-ray.
  • Upper endoscopy is usually reserved for people with severe, recurrent symptoms or para-esophageal hernias that have become symptomatic. It involves the insertion of a lighted, flexible scope into your throat to view your esophagus, stomach, and duodenum.
  • High-resolution manometry (HRM) is a newer technology used to measure the rhythmic contractions of the esophagus as you swallow. This can provide your doctor insights into how severely your swallowing and LES have been impaired.

Blood tests are also performed to check for anemia and other blood abnormalities. A pH test may also be used to measure acidity in the esophagus.

Treatment

Most symptoms of a hiatal hernia can be treated conservatively with OTC medications, lifestyle adjustments, and self-care strategies. Surgery is rarely needed and considered for only the most severe cases.

Medications

The OTC medications commonly used to treat reflux symptoms include:

  • Antacids to neutralize stomach acids, such as Tums, Rolaids, and Gaviscon
  • H2 receptor blockers that reduce the production stomach acids, such as Tagamet (cimetidine) and Zantac (ranitidine)
  • Proton pump inhibitors (PPIs), which are stronger than H-blockers and include Prevacid (lansoprazole) and Prilosec (omeprazole)

Stronger versions of H2 blockers and PPIs are available by prescription.

Lifestyle Changes

Lifestyle changes are those modifiable behaviors that can reduce the frequency and severity of symptoms, including:

Self-Care

Self-care strategies can also help you avoid or better cope with the symptoms of reflux, and may include avoiding tight clothing or belts, elevating the head of your bed, and sitting in an upright position, among other things.

Surgery

Surgery may be considered when a paraesophageal hernia starts to cause gastrointestinal symptoms. Treating the hernia early, while the hiatal space is still relatively small, can significantly reduce the risk of post-surgical complications. Symptomatic paraesophageal hernias are almost always progressive.

Hiatal hernia surgery is typically performed under general anesthesia on either an inpatient or outpatient basis. Many of the surgeries are performed laparoscopically (also known as "keyhole" surgery).

One surgical technique, known as Nissen fundoplication, is performed by wrapping the upper part of the stomach (called the fundus) around the lower esophagus and either stitching or stapling it into place. This reinforces the lower esophageal sphincter and, by doing so, reduces the risk of reflux.

A Word From Verywell

Most hiatal hernias do not require medical management or oversight. If you do develop symptoms, you need to find the strategies, beyond just medications, to help you cope. No two cases are alike, and what may work for someone else may not work for you.

Focus on the lifestyle changes you know you should make, including eating better, exercising regularly, and losing weight. If you have trouble reaching your goals, speak with a nutritionist or personal trainer experienced in metabolic syndrome and other weight problems. 

However, if your symptoms worsen or fail to respond to conservative treatment, ask your doctor for a referral to a gastroenterologist.

Sources:

Roman, S. The diagnosis and management of hiatus hernia. BMJ. 2014; 349:g6154. DOI: 10.1136/bmj.g6154.

Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). Guidelines for the Management of Hiatal Hernia. Los Angeles, California; issue April 2013.