In general, hernias are a condition where some part of an organ protrudes beyond its normal anatomical enclosure, creating a bulge in the surrounding area. A hiatal hernia, in particular, is when a part of the stomach protrudes through the hiatus – an opening within the diaphragm. The diaphragm is a muscular structure that divides your abdomen from your chest.
Types of Hiatal Hernias
When Hiatal hernias occur, they tend to take one of two forms:
1. Sliding Hiatal Hernia
In the sliding type, a part of the stomach and the gastroesophageal junction – the connection between the stomach and the esophagus- slip into the chest. These hernias are related to weaknesses that occur in the tissues which normally anchor gastroesophageal junction to the diaphragm, and to certain activities or conditions which are capable of increasing intra-abdominal pressure. Some of these activities are persistent coughing, retching, heavy lifting, and pregnancy.
Sliding hernias are common in overweight people and women over the age of 50. They are usually small, do not cause issues, and may not require treatment.
2. Paraoesophageal or Fixed Hiatal Hernia
In the paraoesophageal type, the junction remains in its normal position, but a fold of the stomach slips up into the chest to stay between the junction and the diaphragm. This is often the more severe type because it can lead to a restriction to blood flow to the stomach, a complication/ medical emergency known as ‘strangulated hernia’. It is not as common as the sliding type.
Signs and Symptoms of Hiatal Hernias
Common symptoms associated with hiatal hernias include:
- Heartburns which worsen on leaning forward
- Chest pain
- Burping
- Trouble swallowing
- Nausea
- Acid reflux
- Shortness of breath
How is a Hiatal Hernia Diagnosed?
A hiatal hernia can be diagnosed using several tests. Some are:
Barium X-ray
Here, your doctor has you drink a liquid with barium in it before taking an X-ray. The barium forms a coating that fills the inside lining of your digestive tract and provides a clear silhouette of it. The image allows your doctor to note the location of your stomach. If it is protruding through your diaphragm, a hiatal hernia diagnosis is confirmed.
Endoscopy
A second way to diagnose this condition is through an endoscopy. The doctor will slide an endoscope (a flexible, thin tube designed to transport a camera and lights) down your throat and down to your esophagus and stomach. Through an endoscopy machine, the doctor will then be able to see if your stomach is bulging through your diaphragm. Inflammations, strangulations, and obstructions will also be visible. An endoscopy is the gold standard for the diagnosis of hiatal hernias.
Esophageal Manometry
This test is done infrequently. It measures the coordination and force exerted by the muscles of your esophagus, and the rhythmic muscle contractions in your stomach when you swallow. A ‘double high-pressure zone’ or ‘double hump’ confirms the diagnosis. This test has a low sensitivity but high specificity when compared to endoscopy.
How Are Hiatal Hernias Treated?
Most people with hiatal hernias do not experience symptoms and will not need any treatment. If you experience symptoms such as recurrent heartburn or acid reflux, you may need medication or surgery.
Medication and Lifestyle Changes
Medications include antacids such as Rolaids which neutralize stomach acids, H2 receptor blockers to reduce acid production e.g. Cimetidine, and Proton Pump Inhibitors like Omeprazole that block acid production and heal the esophagus.
Your doctor might recommend some lifestyle changes which could help control symptoms. These may include some or all of the following:
1. Avoid eating heavy meals and instead eat several smaller-portioned meals in the day.
2. Maintain a healthy weight.
3. Avoid smoking.
4. Avoid acidic foods and those that trigger heartburn, such as fatty or fried foods, alcohol, chocolate, garlic, onions, tomato sauce, mint, and caffeine.
5. Avoid eating late in the day; eat two or three hours before bedtime.
6. Avoid lying down immediately after a meal.
7. Elevate the head of your bed about six inches to reduce the risk of acid reflux.
8. Do not wear tight clothes or belts that put pressure on your belly.
Surgery
Suppose you have been diagnosed with a hiatal hernia and your problems persist after you make lifestyle changes and start medication. In that case, you may be referred to a skilled doctor who specializes in hiatal hernia surgeries. The specialist will provide you with detailed guidance on what to know about hiatal hernia surgery.
Surgery is recommended for people who are not helped by medications, have pre-cancerous changes or complications such as severe inflammation, ulcers, scarring, or narrowing of the esophagus. There are different types of surgeries used in the treatment of hiatal hernias.
Surgical repair may involve several options such as simply pulling the stomach back into position and then tighten the hiatus to prevent easy passage and reconstruction of the esophageal sphincter.
In the course of the surgery, the surgeon will insert a tiny camera and special surgical tools through several small incisions in the abdomen. The operation is then performed while the surgeon views images from inside the body being displayed on a video monitor (laparoscopic surgery). The surgery takes about an hour, and recovery for about 3-6 weeks.
Hiatal hernia surgery is quite a complex procedure, but when done by skilled surgeons with years of experience in patient management, records show a very high success rate.
