A hiatus hernia occurs when a part of the stomach enters the thorax through an opening in the diaphragm called a hiatus.
The diaphragm is a large muscle that has the shape of a dome and separates the chest from the abdomen.
Most people with a hiatal hernia have no symptoms. However, the hernia can cause heartburn and gastroesophageal reflux .
Hiatal hernia is very frequent among the elderly, 30% of people over 50 suffer from this problem.
However, this percentage is likely to be higher because many people with a hiatal hernia have very mild or non-noticeable symptoms.
Types of hiatal hernia
Slipped hiatal hernia
This is the most common type that affects 80% of people with hiatal hernia. In a hiatal hernia by slip, the junction between the esophagus and stomach (known as the lower esophageal sphincter) and a part of the stomach slides above the diaphragm.
The joint may remain permanently in your chest, but often stays there for a short period of time.
This is because with swallowing the esophageal muscles contract and pull up the stomach. When the chewing is over, the part of the herniated stomach returns to the abdomen.
Paraesophageal Hiatal Hernia
In this type of hernia, the junction between the stomach and the esophagus is attached to the diaphragm, where it should be, but a part of the stomach rises in the thorax next to the esophagus.
A very large paraesophageal hiatus hernia can obstruct the passage of food into the stomach, especially if it compresses the adjacent esophagus and can cause reflux of food in the esophagus.
The gastric ulcer may also form in the herniated stomach.
Fortunately, large paraesophageal hernias are rare.
The exact reasons for which a hiatal hernia develops are not yet known at this time, but it is very likely to develop in people over 50, smokers or obese.
Other factors that increase the risk of having a hiatal hernia include:
- Excessive coughing , vomiting, or physical exertion at the gym;
- A weak diaphragm, this becomes weaker as we age;
- Who did a previous operation for a hiatus hernia;
Hiatus hernia is more common in women than men.
Women usually have symptoms of reflux in pregnancy due to increased pressure in the abdomen when the baby grows.
Diseases such as chronic esophagitis ( inflammation of the inner wall of the esophagus) may cause shortening in the esophagus. This can increase the risk of developing a hiatal hernia.
Hiatus hernia is not caused by anxiety , but other related disorders such as gastroesophageal reflux can be caused or aggravated by anxiety, worry, feelings of guilt and stress.
What are the symptoms of hiatal hernia?
Many people with a hiatal hernia have no symptoms.
Symptoms of acid reflux
The hernia does not cause symptoms in general. However, in the case of hiatal hernia the system that normally prevents the acid from the stomach from flowing back into the esophagus does not work well.
The sphincter may not work properly and the normal pressure of the diaphragm in the esophagus is reduced.
Therefore, the reflux of acids from the stomach into the esophagus is easy.
Reflux acid can cause inflammation of the lower esophagus that can cause one or more of the following symptoms:
- Overall malaise,
- Bitter mouth ,
- A bitter taste in the mouth,
- Difficulty of swallowing (dysphagia).
Like heartburn, these symptoms tend to come and go and are worse after a meal.
Some rare symptoms may occur.
If you have any of these symptoms, it can make it difficult to diagnose because the symptoms can mimic other diseases.
Sometimes a persistent cough (especially at night) is due to irritation of the trachea by acid reflux.
Other symptoms of the mouth and throat that can cause gum problems, bad breath , sore throat , hoarseness and lumpiness in the throat.
Note: Most people with acid reflux do not have a hiatal hernia. In addition, most people with a hiatal hernia have no symptoms of acid reflux.
So if you have a hiatus hernia it does not necessarily mean that the sphincter between the esophagus and the stomach does not work well. It is just that a hiatal hernia increases the chances of a sphincter malfunction so it is more likely to have gastric acid reflux symptoms.
However, anyone with a hiatal hernia suffering from reflux of gastric acid has more severe symptoms associated with acid reflux.
This can happen because with a hiatal hernia, any acid that enters the esophagus is more likely to remain in contact with the inner wall of the esophagus.
What are the possible complications of a hiatal hernia?
The possible complications of long-term acid reflux in the esophagus are:
Stenosis. In case of severe and chronic inflammation can cause scarring and narrowing of the lower esophagus. This complication is rare.
Barrett’s esophagus . In this disease, the cells lining the lower esophagus undergo changes. Modified cells are more likely to become cancerous.
Between 1 or 2 people in 100 with Barrett’s esophagus develop esophageal cancer.
Cancer. The risk of developing esophageal cancer is slightly higher than normal because of acid reflux for a long time.
Other complications include:
- The anemia due to bleeding in the esophagus, blood can be found in the vomitor stool,
- Ulcers in the esophagus,
- Acid reflux can enter the lungs and can cause chronic coughing, difficulty breathing, asthma and rarely pneumonia .
How to diagnose a hiatal hernia?
The first thing to do is a medical examination to find out what the symptoms are.
The doctor should do palpation, auscultation, and percussion to analyze the consistency and sounds emitted from the abdomen.
Then you need to assess the mobility of the stomach to see if it has adhesions or structures that impede movement.
Hiatal hernias are diagnosed per case by making a gastrointestinal radiograph or an endoscopy in the upper abdomen to determine the cause of upper gastrointestinal symptoms or upper belly pain .
On radiography and endoscopy the hiatus hernia appears as a separate sac that lies between the esophagus and the stomach.
This sac is delineated from the lower esophageal sphincter, above and below the diaphragm. However, the hernia may be visible only during swallowing.
Treatment for hiatal hernia
Treatment for a hiatal hernia is done to alleviate and reduce symptoms. Sometimes the doctor or gastroenterologist prescribes pharmacological treatment or gives advice on nutrition.
Surgery may be needed, but it is rare.
You can reduce the symptoms of a hiatal hernia and avoid further problems by making the following lifestyle changes.
- Anyone who is overweight or obese should take a diet to lose excess weight,
- Eat small frequent meals and try not to eat before taming,
- No smoking and no alcohol,
- Wear comfortable clothes that are not tight,
- Staying with your head up from bed before bed,
- Try not to drink too many acidic drinks or that contain caffeine, orange juice, carbonated drinks, coffee, or energy drinks.
- There are some foods that we should not eat like onions, chocolate, spicy or fatty foods.
- Physical activity and physical exercise in a gym are recommended, but you have to avoid exercises to strengthen the abdominal muscles that increase pressure in the abdomen and can aggravate the hernia.
The osteopathy can be useful because it reduces the tension that blocks the movement of bones and organs, therefore, allows for a smooth functioning of the stomach and better digestion.
There are several medications available that can help reduce the symptoms of a hiatal hernia. The most common are antacids that neutralize acid in the stomach.
The effectiveness of antacids varies from person to person. If they are not enough to relieve the symptoms, your doctor may recommend a different medicine.
Surgery to repair hiatal hernia
When should it be done?
A small percentage of cases of hiatal hernia may require surgery. Usually the surgery is reserved for emergency situations and people who can not take medication to relieve heartburn and acid reflux.
Hiatal hernia surgery is often combined with surgery for gastroesophageal reflux disease.
A fundoplication by the technique of Nissen-Rossetti. In this surgery, the surgeon wraps the upper part of the stomach around the lower esophagus. This strengthens the lower esophageal sphincter, making acid reflux in the esophagus less likely.
The operation of a hiatal hernia can be done to:
- Lower the stomach in the abdomen,
- Tighten the diaphragm opening,
- Rebuild a weak esophageal sphincter or remove the herniated part of the stomach.
In some cases, this is done with a single incision in the chest wall (thoracotomy) or in the abdomen (laparotomy).
In other cases, the surgeon may insert a small camera and special surgical instruments through small incisions in the abdomen ( laparoscopy ).
The surgeon performs the operation while viewing images of the inside of the body on a monitor (laparoscopic surgery).
It is probably necessary to stay in the hospital for up to three days after the operation.
Generally, you can return to work within two to three weeks in the case of minimally invasive surgery.
Sometimes, open surgery may be needed to repair the hiatal hernia.
This is done through an incision in the abdomen.
Recovery times are usually longer if surgery is done in the open.