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Hiatal Hernia

The hiatus refers to the opening in the diaphragm (the muscle separating the chest cavity from the abdomen) through which the esophagus passes from the chest to the abdomen.  A hiatal hernia occurs when a small part of the top of the stomach extends into the chest cavity through the diaphragm, usually because the muscles at the hiatus are loose or the opening is large.  Since the hiatus is important in protecting the esophagus from reflux of stomach content and acid, the presence of a hiatal hernia increases the likelihood of reflux.  However, not all patients with a hiatal hernia will have reflux disease

Hiatal hernias are categorized into either sliding or paraesophageal.

SLIDING HIATAL HERNIA

Sliding hiatal hernia (Type I hiatal hernia) is the most common type of hiatal hernia. The stomach slides into the chest cavity through the diaphragm.

A small sliding hiatal hernia may never cause problems or show symptoms. Most patients with symptoms have GERD symptoms, which are managed with acid reducing medications.  Larger sliding hiatal hernias may cause heartburn and regurgitation that do not come under control easily with medications alone. Sometimes, these large hiatal hernias require surgical repair

PARAESOPHAGEAL HIATAL HERNIA

Paraesophageal hernias are types II, III, and IV hiatal hernias. Part of the stomach pushes into the chest cavity next to the esophagus.

Although less common than sliding hiatal hernias, paraesophageal hernias can have more severe symptoms and may require surgical management. Paraesophageal hernias can reduce the stomach’s blood supply, with acute symptoms of chest and abdominal pain, food sticking in the chest, or even bleeding.  In such instances, surgery for repair may be urgently needed.

Patients with Type IV paraesophageal hernias, in particular, may have most of the stomach and sometimes other abdominal organs pushed into the chest cavity. Twisting of the stomach or abdominal organs may cause acute pain. In these situations, the patient should be taken to the emergency department for evaluation and may require emergency surgery. 

CAUSES OF HIATAL HERNIA

Although exact causes of hiatal hernias are not known, events or activities that abruptly increase abdominal pressure may result in a hiatal hernia in otherwise predisposed individuals. Possible causes may include:

  • Chronic coughing;
  • Vomiting;
  • Straining during a bowel movement;
  • Strain during sudden physical activity or lifting heavy objects;
  • Pregnancy;
  • Obesity.

HIATAL HERNIA DIAGNOSIS

It is rare that testing is performed specifically for the purpose of diagnosing a hiatal hernia.  In most instances, testing is performed to evaluate symptoms of reflux disease, and a hiatal hernia is found incidentally.  Rarely, specific testing is performed because a large hiatal hernia is suspected in a patient who develops acute upper abdominal pain. Tests that can show a hiatal hernia include:

  • Endoscopy: Hiatal hernias are most frequently found on endoscopy
  • Barium swallow: the patient swallows a fluid called barium (a metallic, chalky liquid) that will coat the inside of the esophagus and stomach. The radiologist will take x-rays of the digestive organs, which appear on the x-ray due to the barium coating.  This is the most accurate method of measuring the size of a hiatal hernia.
  • Manometry: the doctor guides a thin tube through the patient’s nostril and into his/her stomach. The patient will swallow and sensors on the tube will measure pressure within the esophagus from esophageal muscle contraction.  By looking at the pressure patterns at the bottom end of the esophagus, the presence of a hiatus hernia can be suspected.
  • CT scan: This is sometimes performed in patients with large hiatus hernias, especially paraesophageal hernias, to accurately demonstrate aspects of the hernia before surgery.

HIATAL HERNIA TREATMENT & SURGERY

Small hiatal hernias frequently require no specific treatment.  Instead, consequences from the presence of the hiatal hernia, such as reflux symptoms, are managed with acid lowering medications. 

A large hiatal hernia that is twisting (volvulus) and causing  the stomach’s blood supply to be reduced will require urgent surgery. Hiatal hernias associated with reflux disease that do not come under control with medications are repaired as part of antireflux surgery.  In addition, paraesophageal hiatal hernias with symptoms are typically repaired surgically.

The surgery is usually minimally invasive, only involving a few tiny incisions to the abdomen. A laparoscope (thin, hollow tube with a camera lens attached to the end) is inserted into the abdomen and guided to the affected area. The scope shows pictures of the organs on a monitor for the doctor to watch as he/she pulls the stomach down into its healthy position or reconstructs the diaphragmatic hiatus where the esophagus passes through into the abdomen.  An antireflux procedure (wrapping the top of the stomach around the bottom end of the esophagus, also called fundoplication) is typically performed together with the repair. Patients are usually able to walk the day after the surgery.

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