Hiatal Hernia

Hiatal Hernia

What is a hiatal hernia?

The stomach is normally positioned in the abdominal cavity below a large, thin, dome-shaped muscle, the diaphragm.  The diaphragm separates the abdominal cavity from the chest cavity.  The esophagus, in the chest cavity, passes through an opening or hole in the diaphragm called the hiatus where the esophagus joins the stomach.  A hiatal hernia results when a portion of the stomach protrudes or herniates upwards through the hole (hiatus) in the diaphragm and into the chest cavity.  Usually only a small portion of the stomach herniates up through the diaphragm.  Occasionally the whole stomach can herniate through the diaphragm up into the chest cavity.

There are two main types of hiatal hernias, sliding and paraesophageal.  A sliding hiatal hernia is the most common.  In a sliding hiatal hernia, the junction between the esophagus and stomach as well as a portion of the stomach itself, protrude above the diaphragm.  The herniated portion of the stomach may slide back and forth into and out of the chest cavity.  In a paraesophageal hiatal hernia, the junction between the esophagus and stomach is in its normal place below the diaphragm but a portion of the stomach is pushed above the diaphragm and lies beside the esophagus.

Why do hiatal hernias occur?

Hiatal hernias are common, occurring in 60% of people by age 60.  The cause is unknown and is thought to result from weakening and enlargement of the hiatus or hole in the diaphragm.  Heredity may play a role in some, while in others obesity, straining or heavy lifting may cause the stomach to push up through the enlarged opening.

What are the symptoms of a hiatal hernia?

Most patients with a sliding hiatal hernia have no symptoms.  Acid reflux is associated with a hiatal hernia and can cause heartburn or regurgitation.  Excess belching or upper abdominal and lower chest pressure or pain can also occur.  Prolonged and frequent reflux of acid into the esophagus may cause damage to the esophagus resulting in ulceration and bleeding.  Scarring and narrowing of the esophagus can also occur with chronic reflux and cause difficult or painful swallowing.  Other symptoms of gastroesophageal reflux can include sore throat, hoarseness, excess salivation, the sensation of a lump in the throat (globus), sinusitis, frequent throat clearing, cough, wheezing or asthma.  Chronic reflux can also lead to a condition called Barrett’s esophagus, which can lead to the development of esophageal cancer.

A paraesophageal hernia is not as common as the sliding hiatal hernia.  Paraesophageal hernias can sometimes get trapped or squeezed by the diaphragm and lose blood supply.  This condition, called strangulation, is a serious and often painful condition that requires immediate surgery.

How do I know if I have a hiatal hernia?

Hiatal hernias are diagnosed by either upper GI x-ray or by endoscopy.  Treatment of symptomatic hiatal hernias involves treating gastroesophageal reflux with dietary modifications and medications.  The majority of patients do well with medical treatment.

More patients are now being referred for surgical repair of hiatal hernias, particularly younger patients who may require life-long medical treatment, or patients who do not respond to medical treatment.  The procedure is called laparoscopic fundoplication and involves wrapping the upper part of the stomach, called the fundus, around the lower part of the esophagus.  The wrapped fundus is sutured together around the esophagus (fundoplication).

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