Hiatal Hernia

Last updated April 8, 2016

What are the other Names for this Condition? (Also known as/Synonyms)

  • Hiatus Hernia
  • Paraesophageal Hiatal Hernia

What is Hiatal Hernia? (Definition/Background Information)

  • When a part or whole of an internal organ (or tissues) protrudes through weak areas of the adjoining muscles or connective tissues, the condition is termed as a hernia. Hernia occurs through the weakened area, whenever there is increased pressure or strain on it. They most commonly occur in the abdomen region
  • Medically, there are various types of hernia and the most common ones are:
    • Inguinal hernia
    • Incisional hernia
    • Femoral hernia
    • Umbilical hernia
    • Hiatal hernia          
  • A Hiatal Hernia occurs when the upper portion of the stomach (or any abdominal structure other than the esophagus) enters into the chest cavity (thorax). It enters through the diaphragm, which is a muscular tissue separating the abdomen and chest. The word ‘hiatus’ means a gap in an anatomical region; in hiatal hernia, it is the diaphragm
  • Though the exact cause and mechanism is unknown, it may be caused by elevated pressure in the abdomen due to frequent coughing, stressful bowel movements (such as during constipation), and many other factors. Hiatal Hernia is a very common disorder in the elderly
  • The signs and symptoms of Hiatal Hernia could include abdominal pain, burping, hiccups, swallowing difficulties, coughing, aspiration of food particles into the lungs, and gastroesophageal reflux disease (GERD)
  • Asymptomatic Hiatal Hernias may not require any treatment and the prognosis is good in such cases. But, if the symptoms continue to aggravate, or if other complications develop, then a surgery may be proposed

There are 4 types of Hiatal Hernias. The classification is important, because the indications for treatment differ with the different types.

  • Type I Hiatal Hernia: A sliding Hiatal Hernia occurs when the gastroesophageal junction (the part where the esophagus meets the stomach) slides above the diaphragm, along with the small top portion (cardia) of the stomach. This type accounts for about 95% of all the cases
  • Type II Hiatal Hernia: A fixed Hiatal Hernia occurs when part of the stomach (fundus) protrudes through the esophageal hiatus (the hole in the diaphragm through which the esophagus and vagus nerve pass through). The stomach and esophagus remain in the normal anatomical position below the diaphragm. This type accounts for about 5% of the cases
  • Type III Hiatal Hernia: This is a rare kind of Hiatal Hernia and is a combination of types I and II
  • Type IV Hiatal Hernia: This is another rare type that is associated with a large defect in the diaphragm, allowing other organs, such as the colon, spleen, pancreas, and small intestine, to enter into the chest cavity

Note:

  • Types II, III, and IV are called Paraesophageal Hiatal Hernias
  • The overall prognosis of commonly occurring hiatal hernias is generally good

Who gets Hiatal Hernia? (Age and Sex Distribution)

  • Hiatal Hernias become very common with increasing age. It is estimated that up to 70% of the adults over 70 years, may have Hiatal Hernia
  • Sometimes, it is a congenital (present at birth) condition and may be seen in children
  • Sliding Hiatus Hernia (type I) occurs at an earlier age than Paraesophageal Hiatal Hernias (types II, III, and IV)
  • Paraesophageal Hiatal Hernias are more common in women than men (ratio of 4:1)
  • It is noticed that Hiatal Hernias are generally more common in the developed nations because of chronic constipation, typically due to low-fiber diets

What are the Risk Factors for Hiatal Hernia? (Predisposing Factors)

Any factor that increases the abdominal pressure and/or any factor that causes weakness in the diaphragm and surrounding regions (ligaments) increase one’s risk of Hiatal Hernia. These factors may include:

  • Hiatal Hernia is more common with an advancing age
  • Smoking
  • Chronic abdominal stress due to chronic constipation, chronic coughing, etc.
  • Long-term use of drugs (such as cocaine)
  • Those with weak diaphragm or surrounding regions; or a large hiatus. The weakness may be genetically acquired
  • Pregnant women
  • Significant weight gain

It is important to note that having a risk factor does not mean that one will get the condition. A risk factor increases ones chances of getting a condition compared to an individual without the risk factors. Some risk factors are more important than others.

Also, not having a risk factor does not mean that an individual will not get the condition. It is always important to discuss the effect of risk factors with your healthcare provider.

What are the Causes of Hiatal Hernia? (Etiology)

Even though there is generally no definitive cause for the occurrence of Hiatal Hernia, the following conditions may potentially result in it:

  • Increased abdominal pressure
  • Chronic or intense coughing
  • Extreme tension exerted during bowel movements
  • Pregnancy, labor, and delivery
  • Significant weight gain
  • Intense lifting (heavy weights)
  • Slouching or bending too much over long periods of time
  • Congenital weakness in the diaphragm or surrounding regions; or a large hiatus

What are the Signs and Symptoms of Hiatal Hernia?

Most individuals with Hiatal Hernia do not present any symptoms. It is diagnosed by chance, during upper gastrointestinal diagnostic tests undertaken for other health reasons. The signs and symptoms of Hiatal Hernia may include the following:

  • Hiccups, burping, or belching
  • Bloating, fullness following a meal
  • Mild to major heartburn
  • Aching or painful chest region
  • Trouble swallowing
  • Chronic coughing
  • Abdominal pain in the upper portion
  • Gastroesophageal reflux disease (GERD) symptoms such as bitter taste in the mouth, water brash (regurgitation of stomach contents), or even aspirating food contents into the lungs. In GERD, stomach acids and digestive enzymes flow up into the esophagus, due to a weak sphincter

One should seek immediate medical attention, if any of the following symptoms occur:

  • Heart palpitations, racing
  • Shortness of breath or difficulty breathing
  • Blood in one’s vomit or stool
  • Black, dark, or tarry stools
  • Trouble with swallowing, both foods and/or liquids
  • Chest pain or intense pressure

In the case of a sliding Hiatal Hernia, if blood supply to the stomach is blocked (strangulation), it would cause extreme abdominal pain and potentially severe illness (shock). In such cases, an emergency surgery is necessary.

How is Hiatal Hernia Diagnosed?

There are many different tests that can be used to diagnose a Hiatal Hernia. These may include:

  • Complete medical history and a thorough physical exam
  • Esophago-gastro-duodenoscopy (EGD, a type of endoscopy): A thin flexible tube is pushed through the esophagus, to see the insides of the pharynx (throat), esophagus, stomach, and part of the duodenum
  • Barium swallow x-ray: It is a special type of x-ray in which the individual drinks a liquid (contrast barium) and series of x-rays are taken to visualize the contour of esophagus and stomach
  • High resolution manometry (HRM): A gastrointestinal (GI) motility diagnostic system that is used to measure the pressure activity within the upper gastrointestinal tract
  • Capsule pH test: During an endoscopy, a small capsule is attached to the bottom of the esophagus to record the amount of time it takes for the stomach acid to reflux back up into the esophagus, and also whether or not a heartburn actually occurs, during the reflux
  • CT scan of abdomen and chest may performed in emergency situations, if acute complications are suspected

Many clinical conditions may have similar signs and symptoms. Your healthcare provider may perform additional tests to rule out other clinical conditions to arrive at a definitive diagnosis.

What are the possible Complications of Hiatal Hernia?

The complications of Hiatal Hernia could include:

  • GERD and its complications including erosive esophagitis (inflammation), stricture (narrowing), ulceration, and/or Barrett's esophagus. Barrett’s esophagus is a condition where the inner lining of the esophagus changes to that of the stomach lining, due to acid irritation
  • If Barrett’s esophagus is present for a long time, cancer of the esophagus can occur
  • Volvulus of stomach: This is a medical emergency. In this condition, the stomach rotates on its axis and in the process blood supply to the stomach gets cut-off, causing death of the stomach tissues
  • Obstruction of the portion of the organ that herniates into the chest
  • Perforation of esophagus
  • Anemia is common in paraesophageal hernias
  • Complications occurring outside the esophagus may include asthma, hoarseness, cough, chest pain, and/or aspiration

Complications due to surgery: Nissen fundoplication is the kind of surgery (minimally-invasive) commonly used to treat GERD symptoms of Hiatal Hernia. Some of the complications associated with the surgery include:

  • Intensive scarring
  • Swallowing trouble (dysphagia)
  • Excessive bloating due to gas buildup
  • Rapid gastric emptying - when ingested foods skip past the stomach too fast and enter the small intestine mostly undigested
  • The hernia may recur even after a surgery is performed

How is Hiatal Hernia Treated?

Treatment is often unnecessary, since many Hiatal Hernias (especially the most common sliding type) cause no symptoms.

  • Medications and lifestyle changes may be tried initially for mild symptoms, such as bloating or heartburn, of Hiatal Hernia
    • Weight loss programs if overweight or obese
    • Eating small frequent meals rather than few large meals
    • Eating 4 hours before sleeping or lying down
    • Elevation of the head end of the bed to keep the acid in the stomach (by gravity)
    • Medications for acid reflux include over-the-counter medications, such as antacids and ranitidine, or prescription medications such as omeprazole

  • If the stomach becomes strangulated (when blood supply to the stomach gets cut-off), or the symptoms from the hernia continue to worsen despite conservative approach, surgery may be necessary.
    • Most Paraesophageal Hiatal Hernias may need to be treated surgically
    • Most surgeries are minimally-invasive, performed through small incisions and done laparoscopically. The advantages of this type of surgery are faster healing process - with less risk of the wounds becoming infected, less post-operative pain, quicker recovery, and lesser scarring
    • Most often, these surgeries have a full recovery period of only 2-3 weeks. However, one should avoid lifting heavy objects for up to 3 months following surgery 

How can Hiatal Hernia be Prevented?

Hiatal Hernia cannot be prevented from occurring as the exact cause and mechanism is not known. However, once diagnosed, the symptoms and progression of the condition can be prevented by observing the following measures:

  • Weight loss, if one is obese, is very important
  • Include more physical activities and exercise regularly
  • By undertaking less straining, leaning, or slumping, while performing everyday activities
  • Smoking cessation
  • Sleep at an angle on the bed, with the head raised around 4-6 inches
  • Maintain a healthy diet (by including high fiber) to avoid constipation

What is the Prognosis of Hiatal Hernia? (Outcomes/Resolutions)

  • The overall prognosis of Hiatal Hernia is generally good. Also, most Hiatal Hernias do not cause any symptoms
  • Lifestyle changes, medications, and surgical options can treat most symptoms of Hiatal Hernia
  • However, they may recur in up to 10% of the individuals despite surgical treatment
  • Untreated paraesophageal hernias have the potential for severe and acute complications; it may even result in death in a few individuals. Nevertheless, paraesophageal hernias are uncommon than sliding hernias

Additional and Relevant Useful Information for Hiatal Hernia:

  • Hiatal hernia repair is a procedure indicated for the treatment of objectively documented, relatively severe, gastroesophageal reflux disease (GERD)

The following article link will help you understand hiatal hernia repair surgical procedure:

http://www.dovemed.com/common-procedures/procedures-surgical/hiatal-hernia-repair/

What are some Useful Resources for Additional Information?

American College of Surgeons (ACS)
633 N Saint Clair Street Chicago, IL 60611-3211
Phone: (312) 202-5000
Toll-Free: (800) 621-4111
Fax: (312) 202-5001
Email: postmaster@facs.org
Website: https://www.facs.org

References and Information Sources used for the Article:

SAGES. Guidelines for the Management of Hiatal Hernia - A SAGES Guideline. 2015. Available at: http://www.sages.org/publications/guidelines/guidelines-for-the-management-of-hiatal-hernia/. (accessed on 05/21/2015)

Hiatal hernia. ADAM. 2013. Available at: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002122/.  (accessed on 05/21/2015).

Mayoclinic.org. Hiatal hernia Why choose Mayo Clinic - Diseases and Conditions - Mayo Clinic. 2015. Available at: http://www.mayoclinic.org/diseases-conditions/hiatal-hernia/care-at-mayo-clinic/why-choose-mayo-clinic/con-20030640. (accessed on 05/21/2015)

Helpful Peer-Reviewed Medical Articles:

Antoniou, S. A., Antoniou, G. A., Koch, O. O., Pointner, R., & Granderath, F. A. (2012). Lower recurrence rates after mesh-reinforced versus simple hiatal hernia repair: a meta-analysis of randomized trials. Surg Laparosc Endosc Percutan Tech, 22(6), 498-502. doi: 10.1097/SLE.0b013e3182747ac2

Antoniou, S. A., Koch, O. O., Antoniou, G. A., Pointner, R., & Granderath, F. A. (2012). Mesh-reinforced hiatal hernia repair: a review on the effect on postoperative dysphagia and recurrence. Langenbecks Arch Surg, 397(1), 19-27. doi: 10.1007/s00423-011-0829-0

Dean, C., Etienne, D., Carpentier, B., Gielecki, J., Tubbs, R. S., & Loukas, M. (2012). Hiatal hernias. Surg Radiol Anat, 34(4), 291-299. doi: 10.1007/s00276-011-0904-9

Kotiv, B. N., Priadko, A. S., Vasilevskii, D. I., & Silant'ev, D. S. (2012). [The MESH-technologies in surgical treatment of hiatal hernia and gastroesophageal reflux]. Khirurgiia (Mosk)(4), 59-62.

Weber, C., Davis, C. S., Shankaran, V., & Fisichella, P. M. (2011). Hiatal hernias: a review of the pathophysiologic theories and implication for research. Surg Endosc, 25(10), 3149-3153. doi: 10.1007/s00464-011-1725-y.

Reviewed and Approved by a member of the DoveMed Editorial Board
First uploaded: May 30, 2015
Last updated: April 8, 2016

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