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Hiatal Hernia Definition

The esophagus connects the mouth and throat to the stomach.  It passes through the chest cavity and enters the abdominal cavity through a hole in the diaphragm called the esophageal hiatus.  The term hiatal hernia describes a condition where a part of the stomach that normally is located in the abdominal cavity pushes or protrudes through the esophageal hiatus to rest within the chest cavity.

What Causes A Hiatal Hernia?

Normally, the space where the esophagus passes through the diaphragm is sealed by the phrenoesophageal membrane, a thin membrane of tissue connecting the esophagus with the diaphragm where the esophagus passes through the diaphragm, so that the chest cavity and abdominal cavity are separated from each other.  Because the esophagus shortens and lengthens with each swallow, essentially squeezing food into the stomach, this membrane needs to be elastic to allow the esophagus to move up and down.  Normal physiology allows the gastroesophageal (GE) junction, where the esophagus and stomach meet, to move back and forth from just below to just above the diaphragm.  However, at rest the GE junction should be located below the diaphragm and in the abdominal cavity.  It is important to remember that these distances are very short.

Over time, the phrenoesophageal membrane may weaken, and a part of the stomach may herniate through the membrane and remain above the diaphragm permanently.

  • Decreased abdominal muscle tone and increased pressure within the abdominal cavity may lead to the development of a hiatal hernia.  Thus, people who are obese and women who are pregnant are at an increased risk of 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, and this may weaken the phrenoesophageal membrane.
  • The membrane also may weaken and lose its elasticity as a part of aging.
  • Ascites, an abnormal collection of fluid in the abdominal cavity often seen in people with liver failure, also is associated with the development of a hiatal hernia.

Is There More Than One Type Of Hiatal Hernia?

The most common type of hiatal hernia is a sliding hiatal hernia.  This accounts for 95% of all hiatal hernias and, because a hiatal hernia by itself causes no symptoms, it is unknown how frequently this condition exists in the general population.  With a sliding hernia, the GE junction and a portion of the stomach slides upward into the mediastinum, the space in the chest between the lungs where the esophagus travels and where the heart is housed.  The hernia is more prominent during inspiration when the diaphragm contracts and descends towards the abdominal cavity and when the esophagus shortens during swallowing. 

In a paraesophageal hernia, the gap in the phrenoesophageal membrane is larger, and a greater portion of the stomach herniates into the chest alongside the esophagus and stays there, but the GE junction remains below the diaphragm.  This is due to ligaments that keep parts of the stomach attached to other organs within the abdomen, and, should a paraesophageal hernia occur, parts of the stomach rotate upward to assume their position above the diaphragm.

In a combination of events, should the defect in the diaphragm become larger, the GE junction and more of the stomach can herniate and become displaced into the chest causing both a paraesophageal and a sliding hiatal hernia.

What Are The Signs And Symptoms Of A Hiatal Hernia?

By itself, a hiatal hernia causes no symptoms, and most are found incidentally when a person has a chest X-ray or abdominal X-rays (including upper GI series, and CT sancs, where the patient swallows barium or another contrast material).  It also is found incidentally during gastrointestinal endoscopy of the esophagus, stomach and duodenum (EGD).

Most often if symptoms occur, they are due to gastroesophageal reflux disease (GERD) where the digestive juice containing acid from the stomach moves up into the esophagus.

The stomach is a mixing bowl that allows food and digestive juices to mix together to begin the digestive process.  The stomach has a protective lining that prevents acid from eating away at the stomach muscle and causing inflammation.  Unfortunately, the esophagus does not have a similar protective lining.  Instead it relies on the lower esophageal sphincter (LES) located at the GE junction and the muscle of the diaphragm surrounding the esophagus to act as a valve to prevent acid from refluxing from the stomach into the esophagus.  In addition to the LES, the normal location of the GE junction withing the abdominal cavity is important in keeping acid where it belongs.  There is increased pressure within the abdominal cavity compared to the chest cavity, particularly during inspiration, and the combination of pressure exerted within the lowermost esophagus from the LES, the diaphragm and the abdominal cavity creates a zone of higher pressure that keeps stomach acid in place.

In the situation of a sliding hiatal hernia, the GE junction moves above the diaphragm and into the chest, and the higher pressure zone is lost.  Acid is allowed to reflux back into the esophagus causing inflammation of the lining of the esophagus and the symptoms of GERD.

These symptoms may include the following:

  • heartburn, chest pain or burning
  • nausea, vomiting or retching (dry heaves)
  • burping
  • waterbrash, the rapid appearance of large amount of saliva in the mouth that is stimulated by the refluxing acid
Symptoms usually are worse after meals.  These symptoms may be made worse when lying flat and may resolve with sitting up or walking.

In some patients, reflux into the lower esophagus sets off nervous reflexes that can cause a cough or even spasm of the small airways with the lungs (asthma).  A few patients may reflux acid droplets into the back of their throat.  This acid can be inhaled or aspirated into the lung causing coughing spasms, asthma, or repeated infections of the lung including pneumonia and bronchitis.  This may occur in individuals of all ages, from infants to the elderly.

Most paraesophageal hiatal hernias have no symptoms of reflux because the GE junction remains below the diaphragm, but because of the way the stomach has rotated into the chest, there is the possibility of a gastric volvulus, where the stomach twists upon itself.  Fortunately, paraesophageal hernias are relatively uncommon.  However, volvulus is a surgical emergency and causes difficult, painful swallowing, chest pain, and vomiting.

How Is Hiatal Hernia Diagnosed?

Most often, a hiatal hernia is found incidentally with gastrointestinal X-rays, EGD, and sometimes CT scan, since by itself, it causes no symptoms.  Only when there are associated symptoms of GERD will the patient usually seek medical care.  With symptoms of GERD, it is likely that a hiatal hernia is present since most patients with GERD have hiatal hernia.

Most often, the diagnosis is confirmed by a barium swallow or upper GI series, where a radiologist uses fluoroscopy to observe in real time as the swallowed barium outlines the esophagus, stomach and upper part of the small intestine.  In addition to seeing the anatomy, the radiologist also can comment upon the movement of the muscles that work to propel the barium (and presumably) food through the esophagus into the stomach and beyond.

Endoscopy is a procedure performed under sedation by a gastroenterologist to look at the lining of the esophagus, stomach, and duodenum.  A hiatal hernia may be diagnosed easily in this manner and more importantly, the physician may be able to see complications of GERD from the reflux of acid.  Endoscopy is used to diagnose a scarring with strictures (narrowing of the esophagus) and precancerous conditions like Barrett's esophagus.  Biopsies or small tissue samples may be taken and examined under a microscope.

What Is The Treatment For Hiatal Hernia?

The treatment for hiatal hernia is really treatment for GERD and minimizing acid reflux.  This includes decreasing acid secretion in the stomach, avoiding substances that are irritating to the stomach lining, and mechanical means to keep the remaining acid in the stomach where it belongs.

Hiatal Hernia Medications

Proton pump inhibitor medications are commonly used to decrease acid production. 
These include:

  • omeprazole (Prilosec)
  • lansoprazole (Prevacid)
  • pantoprazole (Protonix)
  • rabeprazole (Achiphex)
  • esomeprazole (Nexium)

Lifestyle Changes

  • Lifestyle changes may include elevating the head of the bed when sleeping to allow gravity to prevent acid from refluxing into the esophagus.
  • Small frequent meals may help instead of eating two or three large meals a day
  • Some foods that should be avoided include spicy, greasy foods, onions, tomatoes and citrus fruits, however, most individuals are generally aware of the foods that trigger heartburn symptoms and avoid them.

Hiatal Hernia Surgery

With the development of proton pump inhibitor medications, medical therapy has decreased the necessity of surgery for sliding hiatal hernias, and it is often only recommended for people who have failed aggressive drug treatment or who have developed complications of GERD like strictures, ulcers, and bleeding or those with repeated pneumonia form aspiration.

Patients with paraesophageal hernias often have no symptoms, and surgery is required only if the hernias become incarcerated and become stuck in the diaphragmatic hiatus or rotate to cause a volvulus.  While this is more commonly seen in older people, paraesophageal hernias also may occur as a congenital condition in neonates and infants.

Most often, the surgery is done as a minimally invasive procedure using a laparoscope.  While there are different techniques, the results are similar and the option recommended is the one the surgeon feels most comfortable performing in a specific situation.

Medically reviewed by Martin E. Zipser, MD; American Board of Surgery

Kohn GP, et al.  Guidelines for the Management of Hiatal Hernia.  Society of American Gastrointestinal and Endoscopic Surgeons.  April 2013.
Society of American Gastrointestinal and Endoscopic Surgeons.  Guidelines for the Management of Hiatal Hernia.

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