Hiatal hernia consists of the protrusion of the stomach through the opening of the diaphragm into the thorax. The opening in the diaphragm through which the esophagus (food tube) passes from the thorax to the abdomen is called the esophageal hiatus. Hiatal hernias affect women more often than men and are more frequent in people who are more than 50 years old. The majority of cases (about 90%) are not symptomatic.
There are two types of hiatal hernias: paraesophageal hernia and sliding hiatal hernia. The first is also known as rolling hernia and occurs when fundus rolls through the esophageal hiatus and into the thorax beside the esophagus. This condition is associated with a high risk of obstruction, bowel twisting and strangulation. On the other hand, sliding hiatal hernia is the most common type of hernia (about 99% of all cases). It happens when both the esophageal junction and a part of the fundus slides upward through the esophageal hiatus into the thorax. This condition is prone to the development of esophageal reflux.
Hiatal hernia is usually idiopathic (no known cause). There are however risk factors associated with the development of hiatal hernia:
- Muscle weakening in the esophageal hiatus
- Prolong increase of pressure in the abdomen - e.g. too much straining during defecating, lifting heavy weights or objects, repeated coughing, persistent vomiting
- Past esophageal surgery
- Anatomic or congenital defect
People with hiatal hernia may be completely asymptomatic or may experience daily symptoms that are similar to those of GERD (gastroesophageal reflux disease):
- Chest pain – the pain is like an angina
- Abdominal pain
- Difficulty breathing especially after eating
Initially, the doctor will ask several questions regarding the patient's family history, past and present medical history, lifestyle habits and dietary status. This will normally be followed by a complete physical examination or assessment to check the location of the pain as well as to check the respiratory status. There are several diagnostic tests that can help confirm the presence of the disease. These include:
- Barium-assisted imaging – the patient will swallow a dye that will allow an X-ray to capture images of the gastrointestinal tract.
- Chest X-ray – will capture images of the respiratory tract to check for any signs of abnormalities.
- Blood test - to check blood markers for infection, anemia or other abnormalities.
- Endoscopy – the doctor uses an endoscope and inserts it through the mouth all the way down to the stomach. This procedure allows a clear visual inspection of the esophagus and stomach. Also, if there are any signs of abnormalities, the doctor can take a sample of the tissue.
- Electrocardiogram (ECG) – uses a frequency that will help the doctor check for any heart problems.
Treating hiatal hernia will depend on the severity of the patient's symptoms or presence of complications. In people with asymptomatic hiatal hernia, treatment is not required. In symptomatic cases, hiatal hernia can be treated either surgically or medically.
Surgery is only necessary in severe cases. Different procedures may be used depending on the degree and specific presentation of the condition. Nissen fundoplication (LNF) is the most common surgery for hiatal hernia. In the laparascopic method, this procedure uses a laparoscope and the repair is done through several incisions in the abdomen. It will wrap the fundus 360 degrees around the gastroesophageal junction using special surgical tools. The laparoscope is connected to a monitor and will serve as the eye of the doctor inside the abdomen by capturing live pictures. Nissen fundoplication may also be performed as an open surgery (in contrast with the laparascopic method). However, open surgery is associated with higher risks and longer recovery time.
Removal of the hernia or reduction of the diaphragm opening through laparotomy (incision in the abdomen) or thoracotomy (incision in the chest wall) may also assist in treating hernia.
Medical treatment can be useful to manage the GERD-like symptoms. H-2 receptor blockers might be recommended to reduce stomach acid production. Proton pump inhibitors will block stomach acid production thereby allowing the esophagus to heal. Antacids may also help by neutralizing stomach acid.
Since there are several available treatments that can help alleviate or cure the disease, the prognosis is good. However, if hiatal hernia is left untreated, the condition can lead to the development of dangerous complications.
Reduce the risk of hiatal hernia by:
- Avoiding strenuous activity
- Maintaining a healthy weight
- Stop smoking
- Raising the head off the bed when sleeping
- Avoiding alcohol
- Avoiding large meals
- Avoid eating too much fatty foods
- Not sleeping right after eating
- Laying down after eating
- Limit or avoid eating foods that can cause heartburn
- Eating a healthy balanced diet that is rich in fiber
Lifestyle changes will provide additional aid in the management of hiatal hernia. These include: not eating anything 1 to 2 hours before bed, and avoiding foods that increase heartburn and alcohol.
Currently, research is focused on the evaluation of new surgical procedures and devices, management of atypical cases, and the association with other conditions such as GERD and Barrett's esophagus.