Overview

When a part of the body pushes into another area where it is not intended, this is known as a hernia. A hiatal hernia is a hernia that develops when the stomach moves above the diaphragm.

The hiatus is an opening in the diaphragm, or the dome-shaped muscle that separates the chest cavity from your abdominal cavity. Normally, your esophagus passes into your stomach through the hiatus. Hiatal hernias occur when the muscle tissue surrounding the hiatus becomes weak and the upper portion of your stomach bulges up through your diaphragm into the chest cavity.

There are two types of hiatal hernias:

  • Sliding hiatal hernia—This is the most common type of hernia. The stomach and the part of the esophagus that joins the stomach slide up into the chest through the hiatus.
  • Paraesophageal hernia—This hiatal hernia is not as common but is more dangerous. The stomach and esophagus remain in their normal position, but part of the stomach moves up through the hiatus, bringing it next to the esophagus. The concern is that the stomach can be “strangled” or have its blood supply cut off.

Symptoms of Hiatal Hernia

If a hiatal hernia is small, there may be no symptoms at all. Larger hiatal hernias can cause heartburn, difficulty swallowing and belching because the hernia may allow food and gastric acid to back up into the esophagus. Medications can sometimes alleviate the symptoms.

What Causes a Hiatal Hernia

The cause of hiatal hernias is not known but they may be caused by:

  • Increased pressure on the abdomen from obesity, pregnancy, coughing or straining from a bowel movement may contribute to the development of a hiatal hernia.
  • Large hiatus—Some individuals may be born with a larger hiatal opening than others and may be susceptible to developing a hiatal hernia.
  • Injury to the area

Risk Factors

People who are overweight or women who are pregnant may be at increased risk for a hiatal hernia. Age also seems to play a role in the development of hiatal hernias, and people over the age of 50 are more likely to develop them.

Tests to Diagnose

Hiatal hernias are often diagnosed with:

  • X-ray of the upper digestive tract—this type of x-ray is called a barium X-ray. You drink a chalky liquid that contains barium, which coats the digestive tract and provides a clear outline of your esophagus, stomach and upper part of the small intestine.
  • Endoscopy—your doctor will pass a thin, flexible tube with a light and video camera down into your esophagus and stomach to evaluate any inflammation.

Treatment Options

Many people do not experience any symptoms of a hiatal hernia so no treatment is required.

If you experience heartburn or reflux, your doctor may suggest medications such as:

  • Antacids—these medications neutralize stomach acid. Some examples of antacids are Maalox, Mylanta, Rolaids, Gelusil and Tums.
  • Medications to reduce acid production
    • H2 receptor blockers — cimetidine (Tagamet HB), famotidine (Pepcid AC), nizatidine (Axid AR) and ranitidine (Zantac 75). These are over-the-counter, but your doctor may prescribe higher doses stronger.
    • Proton pump inhibitors (PPIs) — lansaoprazole (Prevacid 24 HR), omeprazole (Prilosec OTC) and esomeprazole (Nexium), which was recently made available over-the-counter. PPIs block acid production and help the ulcers to heal. These are over-the-counter medications, but your doctor may choose to prescribe higher doses.

Making some small lifestyle changes can also help control the symptoms of acid reflux caused by hiatal hernia. Try some of these modifications:

  • Rather than eating large meals, eat smaller meals several times a day
  • Avoid heartburn trigger foods like spicy foods, citrus fruits, tomato-based foods, fatty foods, chocolate and onions
  • Avoid eating within two hours of bed time
  • Commit to losing some weight if you are overweight
  • Avoid smoking and alcohol
  • Elevate the head of your bed by at least six inches

Surgery

In rare cases, surgery may be required as treatment for serious hiatal hernias. Surgery is usually done only in emergency situations or for individuals who are not experiencing relief from heartburn and reflux.

How the surgery is performed depends on the location and shape of the hernia. The procedure may involve:

  • Pulling the stomach down further into the abdominal cavity and making the opening in the diaphragm smaller
  • Removing the hernia sac
  • Reconstructing a weak esophageal sphincter.

The surgery may be performed by an incision in the chest or an incision in the abdomen.

Laparoscopic surgery is becoming more common because it is less invasive. Small incisions are made in the abdomen, and the doctor inserts the laparoscope to view images of the internal organs on a monitor. Guided by the laparoscope, the doctor performs the surgery through a 5-10mm opening. The advantages include smaller incisions, reduced risk of infection, less pain, little scarring and more rapid recovery.

Most patients are able to walk the day after surgery. There are usually no food restrictions and normal activities can be resumed within a week. Complete recovery takes place within 2 to 3 weeks, but no heavy lifting should be done for at least 90 days after surgery. Although results are extremely successful, there are no guarantees about their permanence and some hiatal hernias return.