Hiatal Hernia

What is a hiatal hernia?

A hiatal hernia happens when the top part of the stomach shoves into the chest through an opening in the diaphragm. The muscle block separating the abdominal cavity and chest cavity is the diaphragm. A hernia arises when a tissue or organ pushes through a weak spot in the tissue barrier containing it. Generally, hernias are frequent, with hiatal hernias being one of the most known types.

Hiatal hernias shove through an already existing weakness within the diaphragm, specifically at the opening, whereby the esophagus connects to the stomach. Doctors refer to the opening as esophageal hiatus, and this is where the term hiatal hernia, or hiatus hernia, originates.

With time, stress can enlarge this opening. Typically, this condition progresses slowly over several years.

What are the different types of hiatal hernia?

The two primary forms of hiatal hernias include sliding hiatal hernias and paraesophageal hiatal hernias. A wide range of individuals experience the sliding type, which is categorized as type 1. The other 3kindsare all paraesophageal hernias.

• Type 1, sliding hiatal hernia: This is the most common form, making up 95 percent of all cases of hiatal hernias. With this type, a section of the esophagus connecting to the stomach sometimes slides upwards through the broadened hiatus and then slips back down.
• Type 2, paraesophageal hiatal hernia: Paraesophageal, meaning ‘beside the esophagus,’occurs when the upper region of the stomach shoves through the hiatus along with the esophagus, creating a bulge near it. This kind is also referred to as a rolling hiatal hernia.
  
• Type 3: This type is a combination of the first two forms. The gastroesophageal junction, where a section of the esophagus joins the stomach, sometimes slides upwards through the hiatus. At times, another area of the stomach protrudes through as well, together with the gastroesophageal junction.
  
• Type 4: This type is uncommon, yet it could be more complex. It occurs when the hiatus is broad enough to allow the herniating of two different organs through it. This involves the stomach along with additional abdominal organs, like the pancreas, a portion of the intestines, or the spleen.

Symptoms

What are hiatal hernia symptoms?

People with sliding hiatal hernia type, which is the most prevalent, are unlikely to feel the hernia. Also, they won’t possibly notice a bulge on the outer area, unlike in other forms of hernias.

Most individuals with hiatal hernias never experience any symptoms. However, for those who do, the common symptoms are usually associated with chronic acid reflux (gastroesophageal reflux disease, or GERD), including:

• A sense of burning in the chest, mainly after eating.
• Noncardiac chest pain. Repeated chest pain that resembles angina but is not.
• A feeling of fullness immediately after eating, accompanied by a burning form of abdominal pain.
• Burping and regurgitation. Rising back of food, acid, and gas into the throat.
• Trouble swallowing. A sensation of a lump in the throat when swallowing.
• Sore throat and hoarseness when speaking caused by irritation due to acid.

Not all people with a hiatal hernia experience acid reflux, and not everybody with acid reflux also has a hiatal hernia. However, if you have lately started noticing these symptoms more frequently, then they could be connected.

Other signs that are likely to indicate hiatal hernia are:

• Nausea caused by compression of the stomach, acid overflow or both.
• Shortness of breath, especially if the hernia is pressing on the lungs.
• Pressure or pain around the lower chest or upper abdomen.
• Usually, these symptoms tend to be more common with bigger paraesophageal hernias.

What Causes A Hiatal Hernia?

A hernia is likely to occur whenever there is a weakness in the tissues separating different compartments of the body. This weak point allows the hernia to push through by creating an opening. A hiatal hernia specifically emerges through an existing opening, the esophageal hiatus, in which the esophagus goes through the diaphragm. This opening just needs to widen slightly for the hiatal hernia to develop.

At times, surgery, particular injuries, or birth defects can lead to initial weakness, resulting in hernia formation. However, it is more commonly because of cumulative damage caused by years of day-to-day stress. Anything producing more pressure in the abdominal cavity can gradually wear down the diaphragm with time. Common factors that contribute to the increased abdominal pressure and the creation of hiatal hernias are:

• Chronic sneezing or coughing
• Chronic straining when pooping (constipation)
• Chronic obesity. A body mass index or BMI above 30
• Recurrent vomiting
• Rigorous workouts or heavy lifting
• Pregnancy and childbirth

Risk factors

In general, hiatal hernias are more likely to occur in individuals who:

• Are at the age of 50 or above
• Are obese or overweight

What are the potential complications of a hiatal hernia?

The common issue that is mostly caused by hiatal hernias is chronic acid reflux. If severe and drugs inadequately manage it, chronic acid reflux could damage the esophagus with time.

Some of the complications linked to chronic acid reflux are:

• Esophagitis: The presence of acid in the esophagus leads to inflammation of the esophageal lining. Chronic inflammation can result in pain, ulcers, swallowing difficulties, and bleeding.
• Esophageal stricture: Prolonged inflammation may lead to scarring of the esophageal tissues. This scar tissue can disrupt swallowing muscles and narrow down the esophagus.
• Barrett’s esophagus: Chronic inflammation can result in tissue alterations known as Barrett’s esophagus. Although it is not dangerous by itself, this condition is regardedas precancerous.

In rare cases, a hiatal hernia can lead to complications if it becomes stuck or pressed in the hiatus. This is more likely, especially with the less common forms of hiatal hernias. The possible complications are:

• Gastrointestinal obstruction: The stomach or a different organ can be stuck and twisted or compressed in the hiatus, forming an obstruction in the gastrointestinal tract.
• Gastritis: Confined acid in the herniated section of the stomach can lead to inflammation, internal bleeding or stomach ulcers.
• Ischemia: The hernia can be tightly pressed such that it cuts its supply of blood. This results inorgan pain and inflammation and, in the end, tissue death.

How is A Hiatal Hernia Diagnosed?

Doctors diagnose hiatal hernias by examining images of the esophagus and stomach. At times, they are discovered incidentally while assessing other issues.

The provider will look for a hiatal hernia if you are experiencing symptoms of acid reflux. They may start by performing an esophageal pH test in order to confirm the presence of acid in the esophagus. If acid is found, further imaging tests will be used to determine the cause.

Diagnostic tests that might help detect hiatal hernia are:

• Chest X-ray: Doctors can order a chest X-ray or radiograph, which utilizes radiation to create still, black-and-white pictures of the inner chest cavity, where the esophagus is located.
• Esophagram: This is a kind of video X-ray of the esophagus while in action. Esophagram capturesreal-time video of the internal areas of the esophagus when swallowing.
• Upper endoscopy: This procedure involves inserting a long tube equipped with a small camera at the tip into the esophagus and stomach to display live pictures on a screen.
• Esophagealmanometry: This test measures the pressure of the muscles using a catheter inserted inside the esophagus. It then creates a topographical pressure map by transforming the data.

Treatment

What are the medical treatments for a hiatal hernia?

To determine the ideal long-term treatment method for your condition, the doctor will carefully assess the nature of the hernia, reflux as well as the symptoms.

The common options are:

• Wait and watch: For hernias that are not bothersome, treatment may not be required. However, the doctor will monitor it, as it may enlarge with time.
• Medications: While medications cannot stop acid reflux, they can lower the stomach’s acid content, making reflux less harmful and easing associated pain.
• Surgery: A minor surgery can help correct a hiatal hernia. A surgical procedure is an option for everyone but isn’t always necessary for all people. Some may require it sooner, while others may need it later.

Medications

For occasional reflux, over-the-counter (OTC) antacids can be used to address the condition. However, for more frequent reflux, a prescription for long-term, everyday use is required.

Proton pump inhibitors (PPIs) are commonly prescribed to help prevent and repair damage caused by acid in the esophagus. Nonetheless, they cannot stop regurgitation or prevent the hernia progression.

Surgery

A surgical procedure to repair a hernia may be recommended when:

• The hernia is accompanied by symptoms or causes complications that drugs cannot prevent.
• Medications lead to side effects affecting health or quality of life.
• The hernia is big enough to pose a risk of significant future complications.

Hiatal hernia surgical procedure corrects the hernia as well as acid reflux by:

• Drawing the stomach and lower esophagus backward beneath the diaphragm.
• Closing the opening in the diaphragm from which the hernia passed through.
• Tightening the intersection between the stomach and esophagus.

The procedure is known as fundoplication, a term that refers to the top region of the stomach called the fundus. The surgery involves wrapping the fundus all over the lower esophagus and attaching it with stitches or surgical staples. This helps tighten the muscle, separating both organs (lower esophageal sphincter). Whenever possible, this operation is performed using minimally invasive laparoscopic surgery.

A Note from MD

Your doctor can accidentally detect the hiatal hernia while diagnosing a different problem. Hiatal hernias are very common; however, if you have a small one that isn’t bothering you, then there’s no need for concern. On the other hand, you might notice a hiatal hernia after experiencing worsening symptoms over the years, finally prompting you to find solutions and relief. It might come as a shock to know that a hernia is the underlying basis of your acid reflux.

The good news is that both hiatal hernias and acid reflux are treatable. The appropriate treatment for you depends on the nature as well as the symptoms of the condition. Mostly, medication and lifestyle modifications are sufficient in managing acid reflux. But, in more serious situations, surgery may be required to repair the hernia. This procedure is highly effective, and after confirming the diagnosis, you will get relief from your symptoms.