Treating Hiatal Hernias

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There are two categories of hiatal hernias, sliding or para-esophageal.

A Sliding hiatal hernia is one in which the gastro-esophageal junction and part of the stomach slides into the chest. This may occur because of weakening of the anchors of the esophagus to the diaphragm, from years of longitudinal esophageal muscle contractions, or from increased pressure in the abdomen. This junction and part of the stomach reside permanently in the chest, or just "slide" into the chest during swallowing.

As an individual swallows, the esophagus contracts and shortens, and pulls on the stomach. After the swallow, the junction falls back into the abdomen. Approximately 90% of all hiatal hernias are the sliding type.

A Para-esophageal hernia is one in which the gastro-esophageal junction remains where it belongs, but part of the stomach is squeezed up into the chest beside the esophagus.

These hernias remain in the chest at all times. With this type of hernia, complications can occur, such as incarceration and strangulation. Incarceration means the hernia is stuck and being squeezed. Strangulation results from the lack of blood supply, leading to death of the tissues involved when incarceration persists too long. Surgical intervention is required.

For approximately 50% of individuals with a hiatal hernia, symptoms are not present. For those who do experience symptoms, it is usually caused by heartburn or acid reflux.

Many individuals with a hiatal hernia also have gastroesophageal reflux disease or GERD. For them, their doctors may prescribe a treatment plan that is similar to the treatment for GERD.

For those individuals who don't have any symptoms, they don't require any treatment for their hiatal hernia. For others, lifestyle changes and medications will control their symptoms.

It is only for a minority of patients who experience severe symptoms of reflux despite lifestyle changes and medications, or who develop complications such as stricture, bleeding or an obstruction, will surgery be considered.

The following are some of the treatment options for a hiatal hernia:

In the case of Sliding hernias, surgery is rarely necessary. The main goal of treatment is to relieve symptoms. Suggestions include:

  • Eat smaller, more frequent meals.
  • Avoid foods and beverages that may cause acid reflux symptoms.
  • Don't eat within three hours before going to bed.
  • Elevate the head of your bed 4 to 8 inches.
  • Don't wear tight clothing around your waist.
  • Avoid bending or stooping after meals.
  • Avoid constipation. Talk to your doctor if you have a problem with this.
  • Don't do any heavy lifting.
  • Lose weight.
  • Stop smoking.
  • Take any medications the doctor prescribes

In the case of Para-esophageal hernias, early surgical intervention is best, given the risk of serious complications, which include:

  • Pulmonary aspiration or pulmonary compromise due to displacement of the lung by the hernia
  • Incarceration or strangulation of the hernia
  • Bleeding in the setting of incarceration or gastric ulceration

If surgery is needed:

  • During hiatal hernia repair surgery, the stomach and lower esophagus are placed back into the abdominal cavity, and the hiatus (the opening in the diaphragm where the esophagus and stomach join) is tightened. The upper part of the stomach (fundus) may be wrapped around the esophagus (fundoplication) to reduce acid reflux.

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