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Hiatal Hernias

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Updated March 29, 2014

A hiatal hernia occurs when the upper part of the stomach pushes through an opening in the diaphragm, and up into the chest. This opening is called a esophageal hiatus or diaphragmatic hiatus.

Studies have shown that the opening in the diaphragm, where the esophagus connects with the stomach, acts as an additional sphincter around the lower part of the esophagus. Normally, the hiatus and the lower esophageal sphincter (LES) rely on each other to keep stomach contents from backing up into the esophagus. It is believed that a hiatal hernia can weaken the LES, and make it easier for stomach acid to back up into the esophagus.

Types of hiatal hernias

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.

What can cause a hiatal hernia?

The cause is unknown, but hiatal hernias may be the result of the weakening of the supporting tissue. Increasing age, obesity, and smoking are no risk factors in adults. Other possible associations include:
  • Pregnancy
  • Tight clothing around the abdomen
  • A sudden physical exertion, such as weight lifting
  • Abdominal injury causing a hole or tear in the diaphragm
  • Constipation or straining during bowel movements
  • Vomiting

Symptoms of a hiatal hernia

A hiatal hernia by itself rarely causes symptoms. Approximately 50% of individuals with a hiatal hernia never experience symptoms. Of those individuals who do experience symptoms, the pain and discomfort they feel is usually due to the reflux of stomach acid into the esophagus, air, or bile.

Most small Sliding hernias are asymptomatic. However, symptoms could include:

  • 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
Paraesophael hernias also tend to be asymptomatic. However, they may include intermittent symptoms that include:
  • Nausea
  • Retching
  • 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

While a doctor may use various tests to diagnose a hiatal hernia, the following tests are routinely used:
  • Upright chest x-ray

  • Barium x-rays
    Barium x-rays, also known as barium swallow, are diagnostic x-rays in which barium is used to diagnose abnormalities of the digestive tract, including hiatal hernias.

  • Upper endoscopy
    The upper endoscopy (also known as esophagogastroduodenoscopy or EGD) allows the doctor to examine the inside of the patient's esophagus, stomach, and duodenum (the first part of the small intestine) with an instrument called an endoscope, a thin flexible lighted tube.

Treatment of hiatal hernias

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

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Sources:
"Facts & Fallacies about Heartburn and GERD." The American College of Gastroenterology. 27 Jul 2007

"Heartburn, Gastroesophageal Reflux (GER), and Gastroesophageal Reflux Disease (GERD)." NIH Publication No. 07–0882 May 2007. National Digestive Diseases Information Clearinghouse (NIDDK). 27 Jul 2007

Jill Sklar, Annabel Cohen. Eating for Acid Reflux: A Handbook and Cookbook for Those with Heartburn. New York, NY: Marlowe & Company, 2003.

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