A hiatal hernia occurs when the upper part of the stomach pushes through the diaphragm. Here, in this article, we discussed the types, causes, symptoms, risk factors, treatment options, and preventive measures of hiatal hernia.
When the upper part of the stomach bulges through the diaphragm, which is the large muscle separating the abdomen and chest, it is called hiatal hernia. Here, the stomach pushes up through the opening in the diaphragm called esophageal hiatus. The food pipe passes through the hiatus and gets connected to the stomach.
A hiatal hernia that is small does not need treatment as it does not cause any symptoms. Such hernias are diagnosed accidentally while performing tests for some other condition. But if the hernia is large, it makes food and acid to regurgitate back into the esophagus and results in heartburn. Such hernias might need surgery. It commonly affects people older than 50 years of age.
The two types of hiatal hernia are:
Sliding hiatal hernia - Here, the stomach and esophagus slide in and out of the hiatus. This type of hernia is small and does not need treatment. It is the most common type.
Fixed hiatal hernia - Here, the part of the stomach that is pushed through the hiatus cannot move back and forth and stays fixed. This type of hernia is not common. It can block the blood flow to the stomach, which needs immediate medical attention.
Usually, a hiatal hernia does not cause any symptoms and is often diagnosed incidentally during chest or abdominal X-ray. The symptoms are caused only when acid regurgitates into the esophagus (acid reflux). The symptoms include:
Sour taste in the back of the throat.
Water brash (Excess saliva production due to acid reflux).
Burning sensation in the chest.
Blood in stools or vomit.
These symptoms worsen after eating and lying down. Walking or sitting up helps relieve symptoms.
Usually, the esophageal hiatus is sealed by the phrenoesophageal membrane, which is a thin membrane connecting the esophagus and diaphragm. These membranes need to be elastic to allow the back and forth movement of the esophagus with each swallow. With age and use, these membranes weaken, and a part of the stomach pushes through the membrane, which results in a hiatal hernia.
The exact cause is still not known, but some of the possible causes include:
Increased pressure in the abdominal cavity, which is seen in obese people, pregnant women, etc.
Injury from trauma or surgery.
Lifting heavy objects.
Ascites (abnormal collection of fluid in the abdominal cavity).
Some of the factors that increase the risk of a hiatal hernia are:
It is commonly diagnosed during tests done to diagnose the cause of heartburn or chest pain. The diagnostic tests include:
Barium X-ray - An X-ray of the upper digestive tract is taken after making the patient drink a thick liquid that coats the gastrointestinal lining. This liquid coating makes the doctor identify the esophagus, stomach, and upper intestine in an X-ray.
Endoscopy - Endoscopy is done by inserting an endoscope, which is a thin, flexible tube with a camera at one end, through the mouth into the digestive tract.
Esophageal manometry - This test is used to measure the rhythmic muscle contractions of the esophagus as the patient swallows. It is also helpful in measuring the force exerted by the muscles of the esophagus.
If you experience any of the symptoms mentioned above, it is best to consult a doctor. Sometimes, a fixed hernia can block the blood flow to the stomach, which is a medical emergency. Get immediate medical attention if you notice the following symptoms:
Unable to pass gas.
A hiatal hernia is treated only if you experience signs and symptoms like recurrent heartburn and acid reflux. The treatment options are:
Instead of a few large meals, eat several smaller meals.
Avoid fatty or fried foods.
Avoid drinking coffee or other caffeinated beverages.
Do not consume alcohol.
Do not eat late in the evening or 2 to 3 hours before going to bed.
Avoid lying down immediately after a meal.
Reduce weight if you are overweight.
Keep your head elevated while sleeping.
Antacids - help neutralize stomach acids.
H-2-receptor blockers (Cimetidine and Ranitidine) - reduce acid production.
Proton pump inhibitors (Lansoprazole and Omeprazole) - help block acid production and heal the esophagus.
If your symptoms are not relieved with medications, or if you developed any complication, then surgery needs to be done. During surgery, the stomach is pulled down into the abdomen and the hiatus opening in the diaphragm is made smaller or the esophageal sphincter is reconstructed or the hernia sac is removed.
It might not be possible to prevent a hernia from forming, but you can prevent a hernia from getting worse. The things you can try are:
Maintaining a healthy weight.
Avoid straining while passing stools.
Avoid exercises that strain your abdomen.
Do not wear very tight belts.
Avoid lifting heavy objects.
Treatment is not needed if your hiatal hernia does not cause any symptoms. Simple lifestyle modifications can help with small hernias. Take antacids or any medicine for acid reflux only after consulting your doctor, as indiscriminate use of antacid can result in kidney disease and diarrhea. Consult a doctor online if your symptoms are not getting better even after taking medicines.
The symptoms experienced by a person suffering due to hiatal hernia is because of stomach acid (HCL) entering the stomach or gas entering the esophagus. It might also be due to bile entering the esophagus. The symptoms experienced are epigastric pain, heartburn, and chest pain. The heartburn that is caused by hiatal hernia is worsened, especially by lying down.
A hiatal hernia in patients with mild to moderate symptoms can be treated by medical management. However, when the disease progresses to severe forms, surgical management is mandatory. During surgery, the affected stomach is pulled back from the thoracic cavity to the abdominal cavity. The loosened diaphragmatic hiatus is also repaired. Sometimes, the esophageal sphincter might also require surgical management in hiatal hernia cases.
The prognosis of the disease is so good. Patients who received a hiatal hernia repair surgery usually spend one to two days at the hospital. People who have other comorbid diseases or life-threatening conditions only spend a longer hospital stay. The healing of the surgical wound will require 2 to 4 weeks, and after the person gets almost no symptoms of the disease, he or she used to get.
If the hiatal hernia is strangulated, it is usually identified with the symptoms that are significantly produced during the disease. The symptoms that indicate acute strangulated hernia are acute pain. It is usually severe and keeps on progressing quickly from the onset of pain. The patient will also undergo other symptoms like excessive fatigue, fever, bloody stools, constipation, inability to pass flatus, inflammation, redness, heat, and severe pain at the site of hernia that also radiates to the surrounding area sometimes. This pain might be more frequently mistaken as chest pain. In order to achieve a proper diagnosis, consult your doctor.
Eating or drinking acidic foods can aggravate hiatal hernia. It could include chocolates and icecreams. The creamy beverages are one of the most common causes of the disease getting aggravated. It might present as severe heartburn in the patient. Activities like lying down immediately after eating foods can also aggravate the condition of hiatal hernia.
The standard gold treatment for hiatal hernia is surgery. The name of the procedure that is done to treat hiatal hernia is known as Nissen's Fundoplication surgery. Once the patient gets treated with this procedure, the prognosis is usually very high. The overall success rate of hiatal hernia surgeries around the world is 90 - 95%. However, the success rate could vary depending on the health condition of the patient.
The hiatal hernia pain is usually located at the upper portion of the stomach, which is medically termed as the epigastric region. It might also radiate to the chest region and mimic chest pain. But, the presence of heartburn rather than a crushing pain that is typical of cardiac issues can differentiate hiatal hernia from more dangerous chest pain.
The axial or longitudinal length of the hiatal hernia from the gastroesophageal junction to the diaphragmatic hernial impression is taken into consideration for identifying the dimension of hiatal hernia. If the length is less than 2 centimeters, it is considered as a small hiatal hernia, and if the axial length is more than 2 centimeters, it is considered as a large hiatal hernia.
Eating smaller meals and separating the usual full meals into frequent small meals is an easy way to prevent the symptoms because large meals can easily cause acid reflux. It is better to avoid large meals. Acid foods like caffeine, chocolates, dairy products, alcohol, tomato sauce, mint should be avoided because they can increase the acidic nature of the stomach.
A hiatal hernia can be treated with medical management until there are no symptoms. If the symptoms are only mild to moderate, it can be managed with medical management. But, once the symptoms start to become severe, especially when the hiatal hernia is strangulated, medical management can not be assured. In such conditions, surgical management is mandatory. When the symptoms are mild, the person can avoid certain foods and eat smaller meals to avoid the progress of the disease.
Certain peculiar symptoms and presentations in the patient can explain that the hiatal hernia is progressing further in severity. Acute and severe intolerable pain is one of the commonest symptoms that indicates a worsened form of hiatal hernia. A bulge that is protruding from the epigastric region can also indicate a worsened hiatal hernia.
When a person is affected with hiatal hernia, sleeping by lying towards the right side of the body can aggravate the disease. Because, when the person lies to his right side, it becomes easy for the gastric contents to reach the esophageal sphincter. This pushes the gastric contents towards the esophagus. This might cause pain and heartburn that might make it difficult for the person to sleep peacefully. So, it would be good and helpful if the person prefers to sleep on the left side.
Hiatal hernia surgery is not one of the life-threatening surgeries. Especially when the surgery is done in a laparoscopic method, the risk of danger is quite low. Since the risk of infection is very low, the procedure is less painful. It also involves less scarring, very few hospital days, and recovery is very good after the surgery. Hiatal hernia surgery is not a dangerous surgery if it is done under proper guidance and therapeutic methods.
Preventing acid reflux is the key to prevent hiatal hernia disease from progressing to its severe form. Everything that can be done could be the avoidance of acid foods, eating smaller meals, and dividing food into several smaller meals. Also, sleep position plays a vital role in preventing the disease from progressing further. However, the severe forms of hiatal hernia cannot be healed if it is strangulated.
Chocolate consists of a substance known as theobromine that triggers acid reflux in patients. This might stimulate the patients suffering from problems like gastroesophageal reflux disease and hiatal hernia. Increasing acid reflux in hiatal hernia can aggravate the disease symptoms and push the disease to severe forms. Thus, it is suggested by doctors to avoid chocolates in case of hiatal hernia. You can also get help from your dietician for a proper diet plan.
Acid reflux disease is a disease in which there are no gross anatomical defects. The main reason for the disease is the problem with either production or clearance of the normal hydrochloric acid of the stomach that is produced by the proton pumps at the parietal cells of the stomach. Due to the excess acid, there is acid reflux into the esophagus that causes the disease. But in the case of hiatal hernia, the problem is anatomic that a part of the stomach is lodged into the thoracic cavity. However, self-diagnosis is not recommended.
Hiatal hernia repair is often performed by general surgeons. If there are any other additional comorbidities in the patient, the doctor of the particular specialty is usually consulted. After getting proper consultation, an ideal treatment plan is formulated.
Though a person might feel the symptoms of hiatal hernia at home, it is not possible to self diagnose the person by himself or herself. It is important for the health care professional to run a series of diagnostic tests like barium swallow, endoscopy and esophageal manometry, etc., to confirm the diagnosis of hiatal hernia.
A hiatal hernia is when the upper proximal part of the stomach or the stomach completely gets herniated into the thoracic cavity through the esophageal hiatus of the diaphragm. It is located in the upper epigastric region of the abdomen and the exact region of the thoracic cavity above it.
When a person is diagnosed with hiatal hernia and feels pain when exercising, he can use antacids to reduce acid formation. Proton pump inhibitors like Omeprazole can also be used to prevent acid reflux for a longer period of time. You should consult your doctor before you start taking medications.
Last reviewed at:
07 Nov 2019 - 4 min read
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