A Hiatal hernia is an anatomic abnormality in which part of the stomach bulges or herniates up into the chest through a widened opening in the diaphragm called the hiatus. Weak structural support around the lower esophagus and upper stomach combined with coughing, vomiting, straining, or physical exertion can cause increased pressure in the abdomen and result in a hiatal hernia. Obesity and pregnancy can also be factors. Although hiatal hernias are present in approximately 15% of the population, most cause no symptoms and usually require no treatment. If acid reflux occurs through a hiatal hernia you may notice:

• heartburn or other chest discomfort
• frequent burping
• acidic taste in your mouth
• recurrent sore throat, loss of voice without being "ill"
• trouble swallowing
• choking, coughing, or wheezing at night
• a sensation of food getting stuck in the middle of the upper abdomen or chest

If you have symptoms that bother you, your physician can help you determine the source of your symptoms. It is important to ensure your symptoms are not related to a heart disease or other problems. The heartburn and pain that hiatal hernia patients sometimes experience can be symptoms of gastroesophageal reflux disease (GERD) or its complications. GERD is defined by the backward flow of irritating stomach contents into the esophagus

Tests Relating to Hiatal Hernia

Upper G.I. Barium Xray – you are asked to swallow liquid barium while being viewed by an X-ray machine. This can identify a hiatal hernia and determine its size and severity.

U.G.I. Endoscopy – Allows your physician to directly see if there is a hernia or its complications such as reflux esophagitis (inflammation in lower esophagus) bleeding, ulcers or Barrett’s Esophagus (permanent damage to the esophagus that carries a higher risk of developing esophageal cancer).

Esophageal manometry – measures the pressure within the esophagus – especially at the LES (Lower Esophageal Sphincter).

24 Hour pH (acid) Test – measures the reflux (backwash) of acid coming from the stomach into the esophagus and correlates this with your symptoms.

What is the esophagus?

The esophagus (food pipe) is a muscular tube that connects your mouth with your stomach. It begins in your neck and passes through an opening in the diaphragm called the hiatus into the abdomen. The diaphragm is an important breathing muscle that separates the chest cavity from the abdomen. The lower part of the esophagus has a one way valve formed by a band of muscle called the lower esophageal sphincter (LES). When you eat, this valve opens (LES relaxes) to allow food to move from your esophagus into your stomach. Between swallows, the LES automatically closes so food and digestive juices cannot reflux or backwash into the esophagus causing symptoms or injury.

                         

Types of Hiatal Hernia

If you have a hiatal hernia, a portion of the stomach is pushed up and slips out of the abdomen into the chest, bulging above the diaphragm. A hiatal hernia results in loosening of the LES and allows stomach acid to move backwards up into the esophagus.

There are two main types of hiatal hernias; sliding and paraesophageal (next to the esophagus).

In a sliding hiatal hernia (Type 1) , the stomach and the section of the esophagus that joins the stomach slide up into the chest through the hiatus. This is the most common type of hiatal hernia.

The paraesophageal hernia (Type 2) is less common, but is more cause for concern. The esophagus and stomach stay in the normal location, but part of the stomach squeezes through the hiatas, along side the esophagus. Although you can have this type of hernia without symptoms, the danger is that the stomach can become “strangled,” or have its blood supply strangled or cut off.

             

                              Type 1                                      Type 2

Treatment

Treatment of large paraesophageal hernias which cause 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 is usually the same as for the associated GERD. If GERD is severe, complicated, or unresponsive to medications and various dietary/physical measures (see list below), 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. In addition, part of the upper stomach is wrapped around the lower esophageal sphincter to increase the pressure at the sphincter and further prevent acid reflux.

Patients with hiatal hernias and GERD can often be treated using the following methods:

• Losing excess weight will reduce abdominal pressure on your stomach and esophagus
• Avoid things that relax your LES -tobacco, alcohol, fatty foods, chocolate, and coffee
• Stay away from things (food, medications) that you know aggravate your symptoms
• Try Over The Counter antacids…talk to your doctor about OTC medicines and/or prescription medicines that may help reduce stomach acid production
• Eat smaller meals. Avoid overeating as large meals can put too much pressure on the LES.
• Avoid bending and stooping.
• After eating wait 3 hours before you lie down
• Raise the head of your bed 4-6 inches, usually on blocks, to prevent reflux
• Avoid tight clothing which can put extra pressure on the stomach
• Surgery is usually needed only for severe, uncontrolled symptoms; it involves tightening the diaphragm and returning the stomach to the abdomen.

Coping with Digestive Problems

1. Avoid spicy, acidic, and tomato-based foods like fruit juices and Mexican and Italian food (eg, pizza).
2. Avoid fast-food hamburgers and other fatty foods.  Chocolate in any form should be avoided by people with gastric reflux.
3. Limit your intake of coffee, tea, alcohol, and cola.
4. Watch your weight.  Being overweight increases pressure in the abdominal area, which can aggravate reflux.
5. Don't gorge yourself at mealtime.  Eat moderate amounts of food.
6. Don't exercise too soon after eating.
7. Avoid bedtime snacks and eat meals at least 3 to 4 hours before lying down.
8. Stop (or at least cut down on) smoking.
9. Elevate the head of your bed with wooden blocks.  Don't elevate your head by using extra pillows; this can increase abdominal pressure.
10. See your physician if you are taking antacids three or more times a week.

Hiatal Hernia Brochure

Please click on the following link to view a printable version of Cheboygan Surgical Associates' Hiatal Hernia Brochure.

File Download: Hiatal_Hernia.pdf

Coping with Digestive Problems Sheet

Please click on the following link to view a printable version of Cheboygan Surgical Associates' Coping with Digestive Problems Sheet.

File Download: Coping_with_Digestive_Problems.pdf

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