Hiatal Hernia: Symptoms, Causes, Types, Diagnosis, Treatment and Lifestyle Changes

Hiatal hernia is a condition where the upper part of the stomach that normally is located just below the diaphragm in the abdomen pushes through the esophageal hiatus to rest within the chest cavity.

Updated: November 4, 2019


Hiatal hernia is a condition where the upper part of the stomach that normally is located just below the diaphragm in the abdomen pushes through the esophageal hiatus to rest within the chest cavity.
Esophageal hiatus is a hole in the diaphragm through which the esophagus (or food tube which connects the throat to the stomach) enters the abdomen after passing passes through the chest. A small hiatal hernia usually doesn't cause problems and can not be diagnosed until it is discovered when checking for another condition. But a large hiatal hernia can allow food and acid back into your esophagus causing heartburn. These symptoms can be relieved by self-care measures or medications. Surgery may be required for a very large hiatal hernia.

Symptoms of Hiatal Hernia:

Mostly small hiatal hernias cause no signs or symptoms. But larger hiatal hernias can cause:

  • Heartburn
  • nausea, vomiting or retching (dry heaves)
  • burping
  • Regurgitation of food or liquids into the mouth
  • Acid reflux or gastroesophageal reflux (GERD), which is backflow of stomach acid into the esophagus
  • Difficulty swallowing
  • Chest or abdominal pain
  • Shortness of breath
  • Vomiting of blood or passing of black stools, which may indicate gastrointestinal bleeding.

Symptoms of hiatal hernias that are similar to acid reflux or gastroesophageal reflux (GERD), which is when stomach acid backs up into the esophagus. This may include:
a burning sensation in your chest (heartburn), acid taste in your mouth, chest pain, stomach pain, sweating, difficulty swallowing, raspy voice, sore throat, or cough.
Usually the symptoms are worse after meals, and when you are lying flat which can be resolved with sitting up or walking.
In some patients, reflux into the lower esophagus sets off nervous reflexes that can cause a cough or asthma. In others acid droplets can get reflux into the back of their throat which can be inhaled or aspirated into the lung causing coughing spasms, asthma, or repeated infections of the lung including pneumonia and bronchitis. As the GE junction remains below the diaphragm, most paraesophageal hiatal hernias have no symptoms of reflux. But if the hernia is large, there is the possibility of volvulus of the stomach, the way the stomach rotates into the chest. In volvulus of the stomach, the stomach twists upon itself causing difficult, painful swallowing, chest pain, and vomiting. Large paraesophageal hernias are relatively uncommon but is a surgical emergency.

Causes of Hiatal Hernia:

Phrenoesophageal membrane is a thin membrane of tissue connecting the esophagus with the diaphragm. Normally, the space  where the esophagus passes through the diaphragm is sealed by the phrenoesophageal membrane. This keeps the chest cavity and abdominal cavity separate from each other. This membrane needs to be elastic to allow the esophagus to move up and down for squeezing food into the stomach. The gastroesophageal (GE) junction is a place where the esophagus and stomach meet, to move back and forth within the hiatus. However, the GE junction should be located below the diaphragm and in the abdominal cavity at rest.
When the phrenoesophageal membrane get weaken for any reason, a part of the stomach may herniate through the membrane which may remain above the diaphragm permanently or move back and forth across the diaphragm causing hiatal hernia.
They may be present at birth or develop later in life. Below listed are some cause of weaken phrenoesophageal membrane resulting in hiatal hernia:

  • As decreased abdominal muscle tone and increased pressure within the abdominal cavity could lead to the development of a hiatal hernia. Thus, people who are obese and women who are pregnant may be at an increased risk for developing a hiatal hernia.
  • People who have repetitive vomiting or those who have constipation and strain to have a bowel movement, increase the intra-abdominal pressure when they strain which may weaken the phrenoesophageal membrane. Persistent and intense pressure on the surrounding muscles, such as while coughing, exercising or lifting heavy objects can also be the cause.
  • As a part of aging, the membrane also may weaken and lose its elasticity.
  • An abnormal collection of fluid in the abdominal cavity often seen in people with liver failure called Ascites, may also be associated with the development of a hiatal hernia.
  • Injury to the area, for example, after trauma or certain types of surgery.

Types of Hiatal Hernias:

There are two types of hiatal hernia. These include:

Sliding hiatal hernia:

A portion of the stomach slides upward through the diaphragm and into the chest in sliding hiatal hernia. The hernia is present during inspiration when the diaphragm contracts and descends towards the abdominal cavity and when the esophagus shortens during swallowing. This is not present during rest.

Paraesophageal hernia:

The gap in the phrenoesophageal membrane is larger, and a portion of the stomach herniates into the chest alongside the esophagus and stays there in paraesophageal hernia. As the phrenoesophageal ligament that keeps parts of the stomach attached to the diaphragm, the junction between the stomach and the esophagus remains below the diaphragm.
If the defect in the diaphragm become larger, the junction between the stomach and the esophagus can herniate through the diaphragm into the chest causing a hernia that is both paraesophageal and sliding.

Diagnosis of Hiatal Hernia:

The disease will be diagnosed when there are associated symptoms of GERD as it causes no symptoms by itself. Most often often hiatal hernia is discovered during a test or procedure to determine the cause of heartburn or chest or upper abdominal pain.
Not necessarily all patients with GERD will have hiatal hernias, but pateint with hiatal hernias will have GERD symptoms.
Endoscopy is a procedure done by a gastroenterologist to look at the lining of the esophagus, stomach, and duodenum.  This procedure is performed under sedation where, a thin, flexible tube equipped with a light and camera (endoscope) will be insereted down your throat, to examine the inside of your esophagus and stomach and check for inflammation.
The physician may be able to see complications of GERD from the reflux of acid in this procedure. Scarring with strictures or narrowing of the esophagus and precancerous conditions like Barrett's esophagus can also be diagnose using this method. For this a biopsies or small tissue samples may be taken and examined under a microscope.
More often, the diagnosis is confirmed by a barium swallow or upper GI series. Here, a fluoroscopy is used by the radiologist to observe in real time as the swallowed barium outlines the esophagus, stomach and upper part of the small intestine. The rhythmic muscle contractions in your esophagus when you swallow can also be measured.

Treatment of Hiatal Hernias:

When people with a hiatal hernia don't experience any signs or symptoms, won't need treatment. But mostly they experience signs and symptoms of GERD, such as recurrent heartburn and acid reflux. In this case treatment for GERD and minimizing acid reflux is required. The goal of the treatment is to reduce acid secretion in the stomach, avoid substances that are irritating to the stomach lining, and to keep the remaining acid in the stomach. You may need medication or surgery for this purpose.

Medications:

Medicines that are recommended if you experience heartburn and acid reflux, include:

Antacids that neutralize stomach acid:

Antacids, such as Mylanta, Rolaids and Tums, may provide quick relief. Overuse of some antacids can cause side effects, such as diarrhea or sometimes kidney problems.

Medications to reduce acid production:

These medications are known as H-2-receptor blockers which include cimetidine (Tagamet famotidine, nizatidine and ranitidine). Stronger versions are available by prescription.

Medications that block acid production and heal the esophagus:

These medications are known as proton pump inhibitors and are stronger acid blockers than H-2-receptor blockers. These medications also allow time for damaged esophageal tissue to heal. Over-the-counter proton pump inhibitors include omeprazole, lansoprazole, pantoprazole, rabeprazole and esomeprazole.

Surgery:

Surgery for sliding hiatal hernias are usually not required as proton pump inhibitor medications are enough for the treatment. Surgery is only recommended for people who have failed aggressive drug treatment and who aren't helped by medications to relieve heartburn and acid reflux or who have developed complications of GERD like severe inflammation or strictures, ulcers, and bleeding or those with repeated pneumonia form aspiration.
Patients with paraesophageal hernias often have no symptoms. Surgery is required only if the hernias become trapped in the chest and become stuck in the diaphragmatic hiatus or rotate to cause a volvulus. Paraesophageal hernias may occur from birth as a congenital condition in infants, but most commonly seen in older people. Most often, the surgery is done as a minimally invasive procedure using a laparoscope. In this procedure, a tiny camera and special surgical tools are inserted through several small incisions in your abdomen. The operation is then performed while your surgeon views images of your internal body part that are displayed on a video monitor. Sometimes surgery is done using a single incision in your chest wall called as thoracotomy.
Sometimes an open surgery can also be done to repair a hiatal hernia. This may involve pulling your stomach down into your abdomen and making the opening in your diaphragm smaller, removing the hernia sac or reconstructing an esophageal sphincter.

Lifestyle Changes:

Making a few lifestyle changes may help control the symptoms and signs caused by a hiatal hernia. Try to:

  • Eat several smaller meals throughout the day rather than a few large meals
  • Avoid foods that trigger heartburn, such as fatty or fried foods, tomato sauce, alcohol, chocolate, mint, garlic, onion, and caffeine
  • Avoid lying down after a meal or eating late in the day
  • Eat at least two to three hours before bedtime.
  • Maintain a healthy weight
  • Stop smoking
  • Elevate the head of your bed 6 inches when sleeping to allow gravity to prevent acid from refluxing into the esophagus.




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