Hiatal hernia

Hernia - hiatal
Last reviewed: August 11, 2011.

Hiatal hernia is a condition in which part of the stomach sticks upward into the chest, through an opening in the diaphragm. The diaphragm is the sheet of muscle that separates the chest from the abdomen. It is used in breathing.

Causes, incidence, and risk factors

The cause is unknown, but hiatal hernias may be due to a weakening of the supporting tissue. Increasing age, obesity, and smoking are known risk factors in adults. Children with this condition are usually born with it (congenital). It often occurs with gastroesophageal reflux in infants. Hiatal hernias are very common, especially in people over 50 years old. This condition may cause reflux (backflow) of gastric acid from the stomach into the esophagus.

Symptoms
Chest pain Heartburn, worse when bending over or lying down Swallowing difficulty

A hiatal hernia by itself rarely causes symptoms. Pain and discomfort are usually due to the reflux of gastric acid, air, or bile.

Signs and tests

Barium swallow x-ray Esophagogastroduodenoscopy (EGD)

Treatment
The goals of treatment are to relieve symptoms and prevent complications. Reducing the backflow of stomach contents into the esophagus (gastroesophageal reflux) will relieve pain. Medications that neutralize stomach acid, decrease acid production, or strengthen the lower esophageal sphincter (the muscle that prevents acid from backing up into the esphagus) may be prescribed. Other measures to reduce symptoms include: Avoiding large or heavy meals Not lying down or bending over right after a meal Reducing weight and not smoking

If these measures do not control the symptoms, or you have complications, you may need surgery to repair the hernia.

Expectations (prognosis)
Treatment can relieve most symptoms of hiatal hernia.

Complications
Pulmonary (lung) aspiration Slow bleeding and iron deficiency anemia (due to a large hernia) Strangulation (closing off) of the hernia

Calling your health care provider

Call your health care provider if: You have symptoms of a hiatal hernia You have a hiatal hernia and your symptoms get worse or do not improve with treatment, or new symptoms develop

Prevention
Controlling risk factors such as obesity may help prevent hiatal hernia.

References
1. Richter JE, Friedenberg FK. Gastroesophageal reflux disease. In: Feldman M, Friedman LS, Brandt LJ, eds. Sleisenger & Fordtran's Gastrointestinal and Liver Disease. 9th ed. Philadelphia, Pa: Saunders Elsevier; 2010:chap 43.
Review Date: 8/11/2011. Reviewed by: George F. Longstreth, MD, Department of Gastroenterology, Kaiser Permanente Medical Care Program San Diego, California. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

What is a hiatal hernia?

A hiatal hernia is an anatomical abnormality in which part of the stomach protrudes through the diaphragm and up into the chest. Although hiatal hernias are present in approximately 15% of the population, they are associated with symptoms in only a minority of those afflicted. Normally, the esophagus or food tube passes down through the chest, crosses the diaphragm, and enters the abdomen through a hole in the diaphragm called the esophageal hiatus. Just below the diaphragm, the esophagus joins the stomach. In individuals with hiatal hernias, the opening of the esophageal hiatus (hiatal opening) is larger than normal, and a portion of the upper stomach slips up or passes (herniates) through the hiatus and into the chest. Although hiatal hernias are occasionally seen in infants where they probably have been present from birth, most hiatal hernias in adults are believed to have developed over many years.

What causes a hiatal hernia?

It is thought that hiatal hernias are caused by a larger-than-normal esophageal hiatus, the opening in the diaphragm through which the esophagus passes from the chest into the abdomen; as a result of the large opening, part of the stomach "slips" into the chest. Other potentially contributing factors include: 1. A permanent shortening of the esophagus (perhaps caused by inflammation and scarring from the reflux or regurgitation of stomach acid) which pulls the stomach up. 2. An abnormally loose attachment of the esophagus to the diaphragm which allows the esophagus and stomach to slip upwards.

Are there different types of hiatal hernias?

Hiatal hernias are categorized as being either sliding or para-esophageal. Sliding hiatal hernias Sliding hiatal hernias, the most common type of hernia, are those in which the junction of the esophagus and stomach, referred to as the gastro-esophageal junction, and part of the stomach protrude into the chest. The junction may reside permanently in the chest, but often it juts into the

chest only during a swallow. This occurs because with each swallow the muscle of the esophagus contracts causing the esophagus to shorten and to pull up the stomach. When the swallow is finished, the herniated part of the stomach falls back into the abdomen. Para-esophageal hernias are hernias in which the gastro-esophageal junction stays where it belongs (attached at the level of the diaphragm), but part of the stomach passes or bulges into the chest beside the esophagus. The para- esophageal hernias themselves remain in the chest at all times and are not affected by swallows. Para-esophageal hiatal hernias A para-esophageal hiatal hernia that is large, particularly if it compresses the adjacent esophagus, may impede the passage of food into the stomach and cause food to stick in the esophagus after it is swallowed. Ulcers also may form in the herniated stomach due to the trauma caused by food that is stuck or acid from the stomach. Fortunately, large para-esophageal hernias are uncommon.

What are the symptoms of hiatal hernia?

The vast majority of hiatal hernias are of the sliding type, and most of them are not associated with symptoms. The larger the hernia, the more likely it is to cause symptoms. When sliding hiatal hernias produce symptoms, they almost always are those of gastroesophageal reflux disease (GERD) or its complications. This occurs because the formation of the hernia often interferes with the barrier (lower esophageal sphincter) which prevents acid from refluxing from the stomach into the esophagus. Additionally, it is known that patients with GERD are much more likely to have a hiatal hernia than individuals not afflicted by GERD. Thus, it is clear that hiatal hernias contribute to GERD. However, it is not clear if hiatal hernias alone can result in GERD. Since GERD may occur in the absence of a hiatal hernia, factors other than the presence of a hernia can cause GERD. Symptoms of uncomplicated GERD include:

heartburn regurgitation nausea

How is a hiatal hernia diagnosed?

Hiatal hernias are diagnosed incidentally when an upper gastrointestinal x-ray orendoscopy is done during testing to determine the cause of upper gastrointestinal symptoms such as upperabdominal pain. On both the x-ray and endoscopy, the hiatal hernia appears as a separate "sac" lying between what is clearly the esophagus and what is clearly the stomach. This sac is delineated by the lower esophageal sphincter above and the diaphragm below. The hernia may only be visible during swallows, however.

How is a hiatal hernia treated?

Treatment of large para-esophageal hernias causing symptoms requires surgery. During surgery, the stomach is pulled down into the abdomen, the esophageal hiatus is made smaller, and the esophagus is attached firmly to the diaphragm. This procedure restores the normal anatomy. Since sliding hiatal hernias rarely cause problems themselves but rather contribute to acid reflux, the treatment for patients with hiatal hernias is usually the same as for the associated GERD. If the GERD is severe, complicated, or unresponsive to reasonable doses of medications, surgery often is performed. At the time of surgery, the hiatal hernia is eliminated in a manner similar to the repair of para-esophageal hernias. However, in addition, part of the upper stomach is wrapped around the lower sphincter to augment the pressure at the sphincter and further prevent acid reflux.

Hiatal Hernia At A Glance

A hiatal hernia is an anatomical abnormality of the esophagus. Hiatal hernias contribute to gastro-esophageal reflux disease (GERD). The symptoms in individuals with hiatal hernias parallel the symptoms of the associated GERD. The treatment of most hiatal hernias is the same as for the associated GERD.

What is a hiatal hernia?

The abdomen and chest are separated by a dome shaped muscle called the diaphragm. The esophagus passes through an opening (the hiatus) in the diaphragm to connect to the stomach. When the upper stomach bulges through this opening this is called a hiatal hernia. There are 3 main types of hiatal hernia: sliding, paraesophageal, and mixed. For many patients and doctors the term hiatal hernia is used to mean Acid Reflux (or GERD). This is NOT correct. There are many patients with severe acid reflux who do not have hiatal hernia, and many patients with large hiatal hernia that do not have acid reflux. It is true that having a hiatal hernia increase the risk of having significant GERD. When GERD is treated surgically in patients who also have a hiatal hernia, the hernia is fixed as part of the surgical procedure.

Sliding hiatal hernia

In a sliding hiatal hernia, part of the stomach moves through the diaphragm so that it is positioned outside of the abdomen and in the chest. The lower esophageal sphincter (LES) often moves up above its normal location in the opening of the diaphragm.

Sliding hiatal hernia is by far the most common type of hiatal hernia, and other then its association with acid reflux, usually does not require repair except in conjunction with anti-reflux surgery.

Paraesophageal hernia and Mixed Hernia

In a paraesophageal hernia, the stomach bulges up through the opening in the diaphragm (hiatus) alongside the esophagus (upside-down stomach). The LES remains in its normal location inside the opening of the diaphragm. This type of hernia most commonly occurs when there is a large opening in the diaphragm next to the esophagus. The stomach and, rarely, other abdominal organs (such as the intestine, spleen, and colon) may also bulge into the chest in a paraesophageal hernia. In a mixed hiatal hernia, the LES is above the diaphragm as in a sliding hiatal hernia, and the stomach is alongside the esophagus as in a paraesophageal hiatal hernia. Paraesophageal and mixed hiatal hernias often have no symptoms or only minimal symptoms. Symptoms may include vague, nonspecific abdominal complaints such as feeling full after a meal and indigestion. Patients may also have vomiting or chest pain. Occasionally patients have minimal symptoms but have anemia that is difficult to explain. This is due to very slow loss of blood from irritation of the stomach at the neck of the hernia. If not treated, the Paraesophageal and mixed hernias can grow. This can result in twisting (volvulus) of the stomach (possibly leading to gangrene), which requires emergency surgical treatment. Because of the risk involved in emergency treatment, it generally is recommended that all people with these types of hernias undergo surgery regardless of the symptoms.

Diagnosis
Barium swallow This is an X-ray test that outlines the esophagus. This test is fairly accurate at diagnosing paraesophageal hernias, but is somewhat less reliable in diagnosing sliding hernia. Endoscopy Used to check the inner lining of the stomach. Somewhat inaccurate in confirming sliding hernia. Esophageal manometry or motility studies These studies can measure how tightly the LES shuts, and they can also check for abnormalities in esophageal pressure and movement. Cardiac evaluation Patients who have chest pain as a GERD symptom may also need an electrocardiogram (called ECG or EKG) and an exercise stress test to rule out heart disease.

 Esophageal pH monitoring This test uses electrodes to measure the pH (acid level) in the esophagus, usually over a 24-hour period. Abdominal ultrasound Uses sound waves to image the abdominal organs to look for other abnormalities that account for your symptoms including gallbladder problems.

Treatment
Sliding hernias usually do not need to be treated except in conjunction with surgical treatment of acid reflux. If left untreated, paraesophageal and mixed hernias can develop serious complications including strangulation and perforation of the stomach. Because of this, when paraesophageal hernias are identified, repair of the hernia is recommended in most patients. Paraesophageal Hernia Repair is usually done laparoscopically, and for patients with significant GERD is sometimes combined with a Nissen Fundoplication to prevent future reflux. Patients with a significant hiatal hernia and acid reflux are not good candidates for the esophyx procedure.

Medications for heartburn If you experience heartburn and acid reflux, your doctor may recommend medications, such as: Antacids that neutralize stomach acid. Over-the-counter antacids, such as Gelusil, Maalox, Mylanta, Rolaids and Tums, may provide quick relief. Medications to reduce acid production. Called H-2-receptor blockers, these medications include cimetidine (Tagamet HB), famotidine (Pepcid AC), nizatidine (Axid AR) and ranitidine (Zantac 75). Stronger versions of these medications are available in prescription form. Medications that block acid production and heal the esophagus.Proton pump inhibitors block acid production and allow time for damaged esophageal tissue to heal. Over-the-counter proton pump inhibitors include lansoprazole (Prevacid 24HR) and omeprazole (Prilosec OTC). Stronger versions of these medications are available in prescription form. Surgery to repair a hiatal hernia In a small number of cases, a hiatal hernia may require surgery. Surgery is generally reserved for emergency situations and for people who aren't helped by medications to relieve heartburn and acid reflux. Hiatal hernia repair surgery is often combined with surgery for gastroesophageal reflux disease. An operation for a hiatal hernia may involve pulling your stomach down into your abdomen and making the opening in your diaphragm smaller, reconstructing a weak esophageal sphincter, or removing the

hernia sac. In some cases, this is done using a single incision in your chest wall (thoracotomy) or abdomen (laparotomy). In other cases, your surgeon may insert a tiny camera and special surgical tools through several small incisions in your abdomen. The operation is then performed while your surgeon views images from inside your body that are displayed on a video monitor (laparoscopic surgery). ifestyle changes may help control the signs and symptoms of acid reflux caused by a hiatal hernia. Consider trying to: Eat several smaller meals throughout the day rather than a few large meals. Avoid foods that trigger heartburn, such as chocolate, onions, spicy foods, citrus fruits and tomato-based foods. Avoid alcohol. Eat at least two hours before bedtime. Lose weight if you're overweight or obese. Stop smoking. Elevate the head of your bed 6 inches (about 15 centimeters).