| What Is a Hiatal Hernia? |
A hernia occurs when one part of your body — usually the intestine — protrudes through a gap or opening into another part of your body. Sometimes this happens when you strain or lift something heavy. But hernias aren't limited to weight lifters. Even infants can be born with what is known as an umbilical hernia, a condition in which the intestine bulges through the baby's abdominal wall near the navel.
Many types of hernias occur in the general area of the abdomen. But hiatal hernias — also known as diaphragmatic hernias — form at the opening (hiatus) in your diaphragm where your food pipe (esophagus) joins your stomach. When the muscle tissue around the hiatus becomes weak, it can allow the upper part of your stomach to bulge through the diaphragm into your chest cavity.
Hiatal hernias are common, occurring in about 25 percent of all people over age 50 — especially in women and in those who are overweight. Most cause no symptoms. In fact, you may never know you have a hiatal hernia unless it's discovered incidentally during a test for another problem.
Small hiatal hernias aren't painful. But larger ones may allow food and acid to back up into your esophagus, which can cause heartburn and chest pain. Self-care measures or medications can usually help ease these symptoms, although very large hiatal hernias sometimes may need surgical repair.
| Signs and Symptoms |
Most hiatal hernias cause no problems at all. But moderate- or large-sized hernias can contribute to heartburn and sometimes to belching or chest pain — common symptoms of gastroesophageal reflux disease (GERD). These symptoms occur when stomach acids back up into your esophagus. They tend to be worse when you lean forward, strain, lift heavy objects or lie down. Your symptoms may also be worse during pregnancy.
In rare cases, the part of your stomach that protrudes into your chest cavity may become twisted. This can lead to bloating, difficulty swallowing or obstruction of your esophagus. Very rarely, blood flow to your stomach may become restricted, causing severe chest pain and difficulty swallowing.
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| Causes |
Your chest cavity and abdomen are separated by the diaphragm — a large dome-shaped muscle that's responsible for a good part of breathing. There's an opening in the diaphragm where the esophagus passes into your stomach. Hiatal hernias occur when the muscle tissue surrounding this opening becomes weak and the upper part of your stomach bulges through the diaphragm into your chest cavity. Anything that puts intense pressure on your abdomen — including persistent or severe coughing or vomiting, straining while going to the bathroom, pregnancy, or lifting heavy objects — can contribute to hiatal hernias.
A hiatal hernia itself can often cause or contribute to gastroesophageal reflux. This happens when a hernia displaces the lower esophageal sphincter a circular band of muscle around the bottom of the esophagus — upward a few inches. Ordinarily, the diaphragm is aligned with the lower esophageal sphincter, which relaxes to allow food and liquid to flow into your stomach when you swallow. The diaphragm supports and puts pressure on the sphincter to keep it closed when you're not swallowing. A hiatal hernia displaces the sphincter above the diaphragm, reducing pressure on the valve and allowing it to open at the wrong time. In that case, stomach acid can flow up into the esophagus.
A hiatal hernia can also cause heartburn if the herniated portion of your stomach becomes a reservoir for gastric acid, which can then easily travel up the esophagus.
| When to Seek Medical Advice |
Many people discover they have hiatal hernias when they see their doctor for another problem, such as heartburn. Most cases of heartburn are mild and temporary. But if your symptoms are severe, occur often, or are accompanied by coughing, wheezing, asthma, a sore throat, difficulty swallowing (dysphagia) or chest pain, talk to your doctor.
If you know you have a large hiatal hernia and experience severe chest pain, difficulty breathing or trouble swallowing, seek medical care right away.
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| Screening and Diagnosis |
Your doctor may discover a hiatal hernia while trying to determine the cause of heartburn, or chest or upper abdominal pain. A hiatal hernia may be identified during one of the following procedures:
- Barium X-ray. During this diagnostic test, you'll drink a chalky liquid (barium) that coats,
fills and outlines your upper digestive tract. This provides a clear silhouette of your esophagus,
stomach and the upper part of your small intestine (duodenum) on an X-ray. A barium X-ray may help
reveal whether the contents of your stomach are backing up into your esophagus.
- Endoscopy. In this test your doctor gently passes a thin, flexible tube equipped with a fiber-optic light and videocamera system (endoscope) down your throat and into your esophagus and stomach to check for inflammation. This is the most sensitive way to check for esophagitis from acid reflux. It can also help determine whether you have a hiatal hernia.
| Complications |
Sometimes a hiatal hernia becomes so large that as much as one-third or more of your stomach protrudes through your diaphragm. This can exert pressure on your lungs or diaphragm.
In addition, some large hiatal hernias may create friction that causes lesions (Cameron erosions) in your upper stomach. If severe, these lesions can bleed and lead to iron deficiency anemia from chronic blood loss.
Pain, bloating and possible obstruction of your esophagus may occur if the portion of your stomach that protrudes into the chest cavity becomes twisted. In very rare cases, nearly your entire stomach may protrude into your chest cavity, causing restricted blood flow to your stomach. This can produce severe chest pain and difficulty swallowing. If this occurs, see your doctor without delay. You may require urgent surgical repair of the hernia.
The most common complication of hiatal hernia, however, is probably GERD. At one time it was thought that hiatal hernias caused most cases of GERD. Now doctors believe that only moderate to large hiatal hernias play a role. Recurrent GERD itself can lead to complications, including:
- Difficulty swallowing. Stomach acid backing up into your esophagus can cause inflammation
and scarring. This narrows your esophagus, making it hard for you to swallow
- Barrett's esophagus. Occasionally, people with gastroesophageal reflux develop Barrett’s
esophagus from repeated and long-term exposure to stomach acid. In this condition, cells similar to
those in the stomach lining develop in the lower esophagus — a process called metaplasia. If you have
Barrett's esophagus, you're at increased risk of developing esophageal cancer. A gastroenterologist can
advise you how best to manage the condition to lessen this risk.
- Esophageal cancer. Most people with Barrett's esophagus don't develop esophageal cancer. However, the prognosis is often poor for those who do. The main symptom of an esophageal tumor is progressive difficulty with swallowing. At first, solid food may be hard to swallow. But as the tumor grows, you may even have difficulty swallowing liquid. Your esophagus may also become blocked, which can cause you to inhale (aspirate) food or liquid into the tube leading to your lungs (trachea). Eventually you may stop eating entirely, which can lead to weight loss and dehydration.
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| Treatment |
If you don't have any symptoms from a hiatal hernia — and most people don't — you probably don't need any treatment. But if you're experiencing recurrent gastroesophageal reflux, you may get relief from a few simple changes in your lifestyle. If you're overweight, losing weight alone may relieve your symptoms.
Medications
If lifestyle changes and weight loss aren’t effective, some medications may help ease symptoms. They include:
- Antacids. Over-the-counter antacids (Maalox, Mylanta, Tums) can neutralize the acidity in
your esophagus and provide relief from heartburn. Keep in mind that these medications don't cure
heartburn — they merely relieve symptoms. Once you stop taking antacids, your symptoms usually return.
- H-2 blockers. These medications reduce the amount of acid secreted by your stomach by
blocking histamine receptors. They include famotidine (Pepcid, Mylanta), cimetidine (Tagamet) and
ranitidine (Zantac, Trite), which are available over the counter. If you have more severe heartburn or
esophagitis, your doctor may prescribe stronger doses of H-2 blockers. It's best to take these
medications before a meal that may give you heartburn. You can also take them after symptoms occur, but
it takes about 30 minutes for them to work. Your doctor may recommend that you take an acid blocker for
a few months, or longer. Occasionally you may experience some side effects such as bowel changes, dry
mouth, dizziness or drowsiness. In addition, H-2 blockers shouldn't be taken with certain other
medications because of the risk of a serious interaction. If you use an acid blocker and also take
other medications, check with your doctor or pharmacist about possible drug interactions.
- Proton pump inhibitors (PPIs). These drugs — which include lansoprazole (Prevacid), omeprazole (Prilosec) and rabeprazole (Aciphex) — are the most effective drugs for the treatment of GERD. They block acid production and allow time for damaged esophageal tissue to heal. They're also convenient because you only have to take them once a day. But they’re more expensive than other GERD medications. Proton pump inhibitors are generally safe and tend to be well tolerated, even for long-term treatment. To prevent possible side effects — such as stomach or abdominal pain, diarrhea or headache — your doctor will likely prescribe the lowest possible dosage.
About 1 in 20 people with a symptomatic hiatal hernia need surgery. This is usually an option only when medications and lifestyle changes fail to relieve severe reflux symptoms, or when you have complications such as narrowing or obstruction of your esophagus, or chronic bleeding.
Large hiatal hernias may also need repair if they cause symptoms such as shortness of breath, difficulty breathing, trouble swallowing or chest pain.
An operation for a hiatal hernia may involve pulling your stomach down into your abdomen and making the opening in your diaphragm smaller, or reconstructing a weak esophageal sphincter. This may be done through a large incision in your chest wall (thoracotomy) or abdomen (laparotomy). It may also be done using special instruments that are inserted through small incisions (laparoscopy) in the same areas.
| Self-Care |
A variety of lifestyle changes can help ease the gastroesophageal reflux that may accompany a hiatal hernia. Some or all of the following measures may help:
- Eat small meals. Large meals can distend your stomach, pushing it into your chest.
- Avoid problem foods and alcohol. Try to avoid alcohol, caffeinated drinks, chocolate,
onions, spicy foods, spearmint and peppermint — all of which increase production of stomach acid and
relax the lower esophageal sphincter. Even decaffeinated coffee can be irritating to an inflamed
esophageal lining. Also try to limit citrus fruits and tomato-based foods. They're acidic and can
irritate an inflamed esophagus.
- Limit fatty foods. Fatty foods relax the lower esophageal sphincter and slow stomach
emptying, which increases the amount of time that acid can back up into your esophagus.
- Sit up after you eat. Wait at least 3 hours before going to bed or taking a nap. By then,
most of the food in your stomach will have emptied into your small intestine, so it can't flow back
into your esophagus. Eating a bedtime snack stimulates more acid formation and further aggravates acid
reflux.
- Don't exercise immediately after eating. Try to wait at least 2 to 3 hours before you engage
in any strenuous activity. Low-key exercise, such as walking, is fine.
- Lose weight. If you're overweight, slimming down helps reduce the pressure on your stomach.
This may well be the most important thing you can do to relieve your symptoms.
- Stop smoking. Smoking increases acid reflux and dries your saliva. Saliva helps protect your
esophagus from stomach acid.
- Avoid certain medications, if possible. Medications to avoid include calcium channel
blockers such as diltiazem (Cardizem, Cartia); the antibiotic tetracycline; nonsteroidal
anti-inflammatory drugs, such as aspirin ibuprofen (Advil, Motrin, others) and naproxen sodium (Aleve);
quinidine (Quinidex); theophylline (Theo-Dur); sedatives and tranquilizers; and alendronate (Fosamax).
If you take any of these medications and suffer from heartburn, talk to your doctor. You may be able to
take other drugs instead. But don't stop taking medications on your own.
- Elevate the head of your bed. If you elevate the head of your bed 6 to 9 inches, gravity
will help prevent stomach acid from moving up into your esophagus as you sleep. Using a foam wedge to
raise your mattress also may help. Don't try to use pillows, which tend to increase pressure on your
abdomen.
- Avoid tight-fitting clothes. They put pressure on your stomach.
- Take time to relax. When you're under stress, digestion slows, which makes GERD symptoms worse. Relaxation techniques such as deep breathing, meditation or yoga may help reduce acid reflux.