Guide to Hiatal Hernias

A hernia occurs when an organ slips through the muscle wall that holds the organ in place. A hiatal hernia occurs when the upper part of the stomach pushes through an opening in the diaphragm -- the muscle that holds the stomach in the abdomen -- and up into the chest. The opening in the diaphragm is called the hiatus, hence the term hiatal hernia.

Normally the hiatus and the lower esophageal sphincter (LES)--the muscle connecting the esophagus with the stomach--act in sync to keep stomach contents from backing up into the esophagus.

Having a hiatal hernia is one cause of Gastroesophageal reflux disease (GERD). There are two reasons for this:

  1. A hiatal hernia can weaken the (LES).
  2. The hiatal hernia can also push acid and other stomach contents above the hiatus, making the acid easily refluxed into the esophagus.

The Four Types of Hiatal Hernias

There are four types of hiatal hernias.

Type 1 Hiatal Hernia

Sliding hiatal hernias are those in which the gastroesophageal junction (the area near the LES) and part of the stomach slide into the chest. This junction can stay permanently in the chest, or just slide into the chest during swallowing. In the latter case, with each swallow, the esophagus contracts, causing the esophagus to shorten and pull on the stomach. After the swallow, the junction falls back into the abdomen. Approximately 90% of all hiatal hernias are the sliding type.

Type 2 Hiatal Hernia

With paraesophageal hernias, the gastroesophageal junction stays 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. Surgical intervention is required.

Type 3 Hiatal Hernia

In type 3 hiatal hernias, the gastroesophageal junction is herniated and the upper part of the stomach is herniated along side the esophagus.

Type 4 Hiatal Hernia

Type 4 hiatal hernias occur when not only the stomach, but also parts of other organs, such as the colon, small intestine or spleen, are herniated.

Causes of Hiatal Hernias

Several factors may contribute to the development of hiatal hernias, including:

  • Obesity
  • Pregnancy
  • Tight clothing around the abdomen
  • Constipation or straining during bowel movements
  • Constant, hard coughing
  • Vomiting
  • Sudden physical exertion, such as weight lifting
  • Abdominal injury causing a hole or tear in the diaphragm

Symptoms of Hiatal Hernias

50% of hiatal hernia patients don't experience any symptoms. For the other 50% of patients, the following symptoms may occur:

  • Heartburn (which is worse when bending over or lying down shortly after eating)
  • Regurgitation (backflow of stomach contents into the back of the throat)
  • Vomiting
  • Gastric reflux (backflow of stomach contents into the esophagus)
  • A sour or bitter taste in the mouth
  • Frequent belching
  • Frequent hiccups
  • Chest pain radiating from below the breastbone (the sternum)
  • Feeling of pressure in the chest
  • A bloated feeling after eating
  • Abdominal discomfort
  • Abdominal pressure, especially soon after eating
  • Discomfort or pain in the stomach
  • Discomfort or pain in the esophagus
  • Gas
  • Unexplained coughing
  • Difficulty swallowing

Diagnosing Hiatal Hernias

There are three procedures used to diagnose a hiatal hernia:

  1. The procedure used most often to detect evidence of a hiatal hernia is called a barium x-ray, also known as a barium swallow. With the barium x-ray, you drink a liquid that contains barium, which will coat the walls of the esophagus and stomach. X-rays are then taken, which can then show if you have a hiatal hernia.
  2. The Upper Endoscopy allows the doctor to examine the inside of your esophagus, stomach and duodenum (the first part of the small intestine) with an instrument called an endoscope, a thin flexible lighted tube. With this procedure the doctor will be able to see if there is a hiatal hernia.
  3. The Bernstein Test, also called the acid perfusion test. attempts to reproduce symptoms of heartburn. It is usually used in combination with barium x-rays to help determine if you have GERD.

Treatment for Hiatal Hernias

Approximately 50% of people who have a hiatal hernia don't have symptoms. 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. If you have heartburn symptoms or GERD, your doctor may prescribe a treatment plan that is similar to the treatment for GERD.

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

  • Lifestyle modifications
  • Medication, which include:
  • Surgery: During hiatal hernia repair surgery, the stomach and lower esophagus are placed back into the abdominal cavity, and the hiatus (the opening in the diaphram 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.

Living With a Hiatal Hernia

Several lifestyle modifications can help reducing the symptoms of heartburn associated with hiatal hernia. These include:

Eat 6 small meals instead of 3 big meals.
This keeps your stomach from getting too full, and reduce gastric pressure.

Don't eat or drink anything 1 to 2 hours before going to bed.
Lying down with a full stomach can cause stomach contents to press harder against the hernia, increasing the chances of refluxed food.

Avoid foods that are known to increase heartburn.
Avoid the foods that can trigger your heartburn, either by increasing acid production and gastric pressure or by loosening the lower sphincter muscle.

Avoid bending over soon after eating.
Bending over shortly after eating a meal may result in regurgitating the food.

Avoid alcohol.
Alcohol increases the production of stomach acid. Alcohol also relaxes the lower esophageal sphincter (LES), allowing stomach contents to reflux back up into the esophagus. This is compounded if you have a hiatal hernia.

Sleep with your head and shoulder on an incline.
With the head higher than the stomach, gravity helps reduce this pressure, and keeps stomach contents where they belong--in the stomach.

Don't wear clothing that constricts the stomach.
Clothing, such as slenderizing undergarments, can squeeze the stomach, forcing food up against the hiatal hernia, and causing reflux.

Don't smoke.
Smoking stimulates the production of stomach acid. Smoking can also weaken and relax the lower esophageal sphincter.

Avoid activities that cause abdominal strain.
This includes heavy lifting and straining during bowel movements.

Recipes and Nutrition Ideas

Nutrition Ideas for Heartburn

This information is designed for chronic heartburn sufferers. However, part of the treatment for hiatal hernias is changes in diet. Usually the foods that heartburn sufferers can and can't eat can help gastroparesis sufferers also. Discuss this with your doctor. It is a good idea to also discuss this with your doctor.

Conditions Most Often Associated with Hiatal Hernias

Although Barrett's esophagus and erosive esophagitis can be associated with hiatal hernias, many more individuals who have a hiatal hernia also suffer from GERD.

Studies have shown that the hiatus acts as an additional sphincter around the lower part of the esophagus. Normally the hiatus and the lower esophageal sphincter (LES)--the muscle connecting the esophagus with the stomach--line up with each other to keep stomach contents from backing up into the esophagus. A hiatal hernia can weaken the (LES) and cause reflux. The hiatal hernia results in the retention of acid and other stomach contents above the opening (hiatus) and can result in this being easily refluxed into the esophagus.