A hiatal hernia is a condition in which a weakness or actual gap or tear in the large muscle of the diaphragm serves as an opening through which the stomach can enter the chest. Hiatal hernias can exist at birth (congenital hiatal hernia) or can develop later in life.
The diaphragm is a large dome-shaped sheet of muscle tissue that spans from the left to the right ribcage. It divides the chest area (thoracic cavity) from the abdominal cavity. The esophageal hiatus is the area of the diagphragm where the esophagus penetrates, joining the stomach below.
Along with other muscles of the abdomen and thoracic cavity, the diaphragm plays an important role in the process of respiration (breathing). During inspiration (breathing in), the muscle of the diaphragm contracts. This increases the volume of the thoracic cavity, and suction allows air to enter the lungs. During expiration, the diaphragm relaxes, and air is expelled from the lungs. The esophagus passes through an area of the diaphragm (the hiatus) on the way to the stomach, which helps prevent the backflow of stomach acid up the esophagus. The diaphragm plays a role in other functions, by virtue of its ability to increase pressure within the abdomen (intra-abdominal pressure)—in this capacity, it is crucial to the acts of vomiting, defecation, and urination.
A hiatal hernia can occur due to an injury, or can develop over time due to some inherent weakness in the muscle fibers. Greatly increased intra-abdominal pressure, as may occur during pregnancy, can also induce a hiatal hernia. The following factors may contribute to the development of a hiatal hernia:
- Family history of hiatal hernia
- Repeated straining due to constipation
- Heavy lifting
- Chronic cough
- Extreme bouts of violent vomiting
- Age (about 60% of people develop some degree of hiatal hernia by the time they reach the age of 60)
A hiatal hernia occurs when the stomach enters the chest cavity through a weakness or tear in the area of the diaphragm where the esophagus passes through. The most common form of hiatal hernia occurs when the gastroesophageal junction (the area where the esophagus enters the stomach) slides upward through the hernia opening. This is referred to as a sliding hiatal hernia. A rolling or paraesophageal hiatal hernia is much more rare. In this instance, the gastroesophageal junction doesn’t protrude up into the thoracic cavity; instead, a portion of the stomach slides up alongside the esophagus, and protrudes into the chest cavity through the hiatal opening. This type of hiatal hernia is more dangerous, since there is a risk that the narrow confines through which the stomach protrudes will prevent proper blood circulation into this area of the stomach, causing its tissue to become oxygen deprived (strangulated).
While some people can have a hiatal hernia without any recognizable symptoms, other people have clear-cut discomfort related to the condition. Symptoms of a hiatal hernia are very similar to symptoms of gastric acid reflux, and include
- Chest pain
- Frequent belching
Symptoms often get worse based on position (lying down, leaning forward) and activity (lifting heavy objects, straining for any reason). Over time, symptoms can worsen and cause coughing and asthma-like symptoms, sore throat, and swallowing problems (dysphagia). Anemia can develop when chronic acid reflux causes esophagitis with erosions of the esophagus or upper stomach.
Hiatal hernia is sometimes diagnosed when a chest x ray is performed for some other reason. In other instances, tests such as a barium swallow (upper GI series) or upper endoscopy may be performed specifically to look for the presence of a hiatal hernia.
Treatment of a hiatal hernia often starts with treatment of the symptoms of gastroesophageal reflux that it induces, including medications such as antacids, H-2 blockers, and proton pump inhibitors. Practical recommendations include weight loss, stopping smoking, elevating the head of the bed at night, so that gravity discourages acid reflux, adjusting the diet to avoid constipation (and therefore straining at stool), and avoiding activities that cause straining (such as heavy lifting).
In some cases, surgical interventions will be required, particularly with very large hiatal hernias or with the rolling or paraesophageal form of hiatal hernia. Several surgical approaches may be utilized, all with the purpose of pulling the stomach back down into the abdomen, and decreasing the size of the hiatal opening. The surgery may be performed through an incision in the chest (thoracic access), abdomen (abdominal access), or using minimally invasive, laparoscopic techniques. Some of the surgeries used include Nissen fundoplication, Belsey (Mark IV) fundoplication, and Hill repair.
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Rosalyn Carson-DeWitt, MD
A hiatal hernia is an abnormal protrusion of the stomach up through the diaphragm and into the chest cavity.
A hiatal or diaphragmatic hernia is different from abdominal hernias in that it is not visible on the outside of the body. With a hiatal hernia, the stomach bulges upward through the esophageal hiatus (the hole through which the esophagus passes) of the diaphragm. This type of hernia occurs more often in women than in men, and it is treated differently from other types of hernias.
Causes & symptoms
A hiatal hernia may be caused by obesity, pregnancy, aging , or previous surgery. About 50% of all people with hiatal hernias do not have any symptoms. For those who do have symptoms, they include heartburn , usually 30–60 minutes after a meal, or mid-chest pain due to gastric acid from the stomach being pushed up into the esophagus. The pain and heartburn are usually worse when lying down. Frequent belching and feelings of abdominal fullness may also occur.
The diagnosis for a hiatal hernia is based on a person's reported symptoms. The doctor may then order tests to confirm the diagnosis. If a barium swallow is ordered, the person drinks a chalky white barium solution, which will help any protrusion through the diaphragm to show up on the x ray that follows. Currently, a diagnosis of hiatal hernia is more frequently made by endoscopy. This procedure is done by a gastroenterologist (a specialist in
digestive diseases). During an endoscopy the person is given an intravenous sedative and a narrow tube is inserted through the mouth and esophagus, into the stomach where the doctor can visualize the hernia. The procedure takes about 30 minutes and may cause some discomfort, but usually no pain. It is done on an outpatient basis.
Dietary and lifestyle adjustments to control a hiatal hernia include:
- Avoiding reclining after meals.
- Avoiding spicy foods, acidic foods, alcohol, and tobacco.
- Eating small frequent bland meals to keep pressure on the esophageal sphincter.
- Eating a high-fiber diet.
- Raising the head of the bed several inches with blocks to help both the quality and quantity of sleep.
Visceral manipulation done by a trained therapist can help return the stomach to its proper positioning. Deglycyrrhizinated licorice (DGL), helps balance stomach acid by improving the protective substances that line the stomach and intestines and by improving blood supply to these tissues. DGL does not interrupt the normal function of stomach acid.
There are several types of medications that help to manage the symptoms of a hiatal hernia. Antacids are used to neutralize gastric acid and decrease heartburn. Drugs that reduce the amount of acid produced in the stomach (H2 blockers) are also used. This class of drugs includes famotidine (sold under the name Pepcid), cimetidine (Tagamet), and ranitidine (Zantac). Omeprazole (Prilosec) is not an H2 blocker, but is another drug that suppresses gastric acid secretion and is used for hiatal hernias. Another option may be metoclopramide (Reglan), a drug that increases the tone of the muscle around the esophagus and causes the stomach to empty more quickly.
Hiatal hernias are treated successfully with medication and diet modifications 85% of the time. The prognosis remains excellent even if surgery is required in adults who are otherwise in good health.
Some hernias can be prevented by maintaining a reasonable weight, avoiding heavy lifting and constipation , and following a moderate exercise program to maintain good abdominal muscle tone.
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