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Hiatal Hernia

Definition


Disease: Hiatal Hernia Hiatal Hernia
Category: Digestive diseases
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Disease Definition:

When one part of the body protrudes through a gap or opening into another part, a hernia occurs. At the opening in the diaphragm where the esophagus joins the stomach, is where a hiatal hernia forms. A hiatal hernia occurs when a part of the stomach pushes through this opening.


If the hiatal hernia is small, the patient may never even know that they have it unless it is discovered when checking for another condition because most small hiatal hernias don't cause problems. However, a large hiatal hernia could lead to heartburn and chest pain because it may allow food and acid to back up into the esophagus. Sometimes, very large hiatal hernias may need surgical repair. However, symptoms are  usually relieved via medications or self-care measures.

Work Group:


Prepared by: Scientific Section

Symptoms, Causes

Symptoms:

Most small hiatal hernias don't cause any problems.
However, when stomach acids back up into the esophagus, larger hernias may cause some of these signs and symptoms:

 

  • Nausea
  • Belching
  • Heartburn
  • Chest pain


These signs and symptoms may worsen during pregnancy. Moreover, when the patient leans forward, lifts heavy objects, lies down or strains, these signs and symptoms may get worse.


In some rare cases, the part of the stomach that protrudes into the chest cavity may become twisted (strangulated) or have its blood supply cut off, which could cause:

 

  • Dysphagia, which is difficulty swallowing
  • Obstruction of the esophagus
  • Severe chest pain

Causes:

What exactly causes hiatal hernias is still not clear. The diaphragm, which is a large dome-shaped muscle that is responsible for a major part of normal breathing, separates the chest cavity and abdomen. Through the hiatus, which is an opening in the diaphragm, the esophagus passes into the stomach. When the muscle tissue surrounding this opening becomes weak and the upper part of the stomach bulges up through the diaphragm into the chest cavity, hiatal hernias occur.


PRESSURE ON THE ABDOMEN:
In some cases, people develop a hiatal hernia after an injury to the area. Other people are born with an unusually large hiatal opening, or an inherent weakness. However, anything that puts intense pressure on the abdomen such as straining while going to the bathroom, lifting heavy objects, persistent or severe coughing, vomiting, pregnancy or an increased abdominal fluid could lead to a hernia.

Complications

Complications:

ANEMIA AND BLEEDING:
Some large hiatal hernias have lesions in the upper stomach. If these lesions are severe, they could bleed and lead to iron deficiency anemia due to chronic blood loss.


REDUCED BLOOD FLOW TO STOMACH:
In some cases, a hernia could become so large that one-third or more of the stomach protrudes through the diaphragm, which puts extra pressure on the lungs or diaphragm. Additionally, the part of the stomach that protrudes into the chest cavity occasionally becomes twisted or cuts off the blood flow to the rest of the stomach, which causes difficulty swallowing and severe chest pain. The patient should see a doctor right away in case this occurs because they may require immediate surgical repair of the hernia.


GERD:
GERD (GastroEsophageal Reflux Disease) is a common complication of hiatal hernia. Most cases of GERD were once thought to be caused by hiatal hernias. However, it is now believed that only larger hiatal hernias play a role. When the lower esophageal sphincter, which is a circular band of muscle around the bottom of the esophagus, becomes slightly displaced due to a hernia, GERD may occur.
The diaphragm is ordinarily aligned with the lower esophageal sphincter, which relaxes to allow food and liquid to flow into the stomach when a person swallows. In order to keep the sphincter closed when the person is not swallowing, the diaphragm supports and puts pressure on it. However, the sphincter will be raised above the diaphragm due to a hiatal hernia, which will reduce pressure on the valve. In this situation, the sphincter muscle will open at the wrong time allowing stomach acid to back up into the esophagus.
If the herniated portion of the stomach becomes a reservoir for gastric acid, which could easily travel up the esophagus, a hiatal hernia could cause heartburn.  


Recurrent GERD could also cause some complications, such as:


Difficulty swallowing:
Inflammation and scarring could be caused when the stomach acid backs up into the esophagus, which will narrow the esophagus, making it difficult to swallow.


Barrett's esophagus:
In some cases, repeated and long-term exposure to stomach acid due to GERD could cause Barrett's esophagus. In such case, similar cells to those found in the stomach lining develop in the lower esophagus. One will be at an increased risk of developing esophageal cancer in case they have Barrett's esophagus. In order to know how to best manage the condition and lessen the risk, one should talk to a gastroenterologist, a doctor that specializes in stomach and intestinal problems.


Esophageal cancer:
An esophageal tumor makes swallowing increasingly difficult and for some people, eventually impossible. Most people with Barrett's esophagus don't develop esophageal cancer. However, for those who do, the prognosis is usually poor.

Treatments:

The patient won’t probably need any treatment if they don't have any signs or symptoms from a hiatal hernia and most people don't. However, the patient could get relief from a few simple changes in their lifestyle if they are experiencing recurrent gastroesophageal reflux. Losing weight alone could relieve symptoms if the patient is overweight.


MEDICATIONS:
Some medications could help ease symptoms if lifestyle changes and weight loss aren't effective. Some of these medications could be:


H-2 blockers:
By blocking histamine receptors, these medications reduce the amount of acid secreted by the stomach. Some over-the-counter examples include nizatidine, cimetidine, ranitidine and famotidine. However, the patient may be prescribed stronger doses of H-2 blockers if they have more severe heartburn or esophagitis. These medications should be taken before a meal that may cause heartburn, they could also be taken after symptoms occur, but they take about 30 minutes to start working. The patient may be recommended taking an acid blocker for a few months or longer. In some cases, dizziness, bowel changes, drowsiness or dry mouth may be experienced as side effects. Also, because of the risk of a serious interaction, H-2 blockers shouldn't be taken with certain other medications. The patient should check with their doctor or pharmacist about possible drug interactions in case they use an acid blocker and also take other medications.


Antacids:
To neutralize the acidity in the esophagus and provide relief from heartburn, the patient may take over-the-counter antacids. However, they should know that these medications only relieve symptoms, they don't cure heartburn and the symptoms usually return once the medications are stopped.


Proton pump inhibitors (PPIs):
For the treatment of GERD, these drugs are the most effective. They work by blocking acid production and allowing time for damaged esophageal tissue to heal. Although these medications are more expensive than other GERD medications, they're convenient because they are taken only once a day. These medications are generally safe and well tolerated, even for long-term treatment. The patient will probably be prescribed the lowest effective dosage in order to prevent possible side effects such as headache, stomach or abdominal pain or diarrhea. If the  patient is taking other medications, they should check with their doctor or pharmacist about possible drug interactions.
Some examples of proton pump inhibitors are rabeprazole, esomeprazole, lansoprazole, omeprazole, pantoprazole.


SURGICAL REPAIR:
Surgery may be needed in some cases of a hiatal hernia. If the patient experiences complications such as narrowing or obstruction of the esophagus, or chronic bleeding, or if medications and lifestyle changes fail to relieve severe reflux symptoms, surgery will be considered. In case large hiatal hernias cause symptoms such as difficulty breathing or swallowing, chest pain or shortness of breath, they may also need surgery.


Operations for a hiatal hernia could be done by pulling the stomach down into the abdomen and making the opening in the diaphragm smaller, reconstructing a weak esophageal sphincter, or removing the hernia sac. This could sometimes be done by using a single incision in the abdomen (laparotomy) or chest wall (thoracotomy). In other cases, instruments and a fiber-optic camera may be inserted through several small incisions in the abdomen. Then, the operation will be performed as the surgeon views the images on a video monitor. This method is called laparoscopic surgery.


In most cases, a laparoscopic surgery requires a shorter hospital stay and it causes less pain and scarring than a laparotomy or a thoracotomy. The experience of the surgeon and the type of the hernia will determine the most appropriate procedure.

Prognosis:

Not Available

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